Progress Notes: The Narrative

GIRPS

G

Goal(s) and Objective(s)

What Goal(s) and objective(s) from the ITP were addressed?

I

Intervention

What were the interventions used by staff?

R

Response

How did the recipient Respond to each intervention(s)?

P

Plan

What is the Plan for the next session?

S

Significant Observations

What are the Significant observations?

Unless the staff member is a clinician, the Significant Observations section should not look like a mini-mental status exam. 

The staff member should include what they will do in response to what was observed. 

For example, observed presence of vertical cuts on wrists.   A phone call was placed to 911 and first aid was applied using direct pressure.  Then called clinical supervisor with the result that the functional assessment will be updated regarding the presence of self-injurious behavior.