Important Steps, Inc.- Session Note Instructions-- NYC EIP- 08-01-11

1. A Session Note must be completed for each session.

2. Complete all areas as follows:

• Child’s Name, DOB, and EI number: Make sure this information is consistent with the information in the EI system (do not use nicknames).

• Interventionist’s Name: The individual providing the intervention.

• Discipline: The appropriate discipline of the interventionist (e.g., PT, ST).

·  Frequency and Duration: As per IFSP and Assignment from Important Steps, Inc.

• Location of Service: Where the session took place, (e.g., home, facility-based, community location)

• Date and Time: The date and time during which the session took place. Please circle “am/pm”.

• Service Type: The service type as listed on the IFSP, (i.e. Speech Therapy (ST)or Family Training-FT/ST)

• Date Note Written: The date the session note was completed (should be the same as the date of service).

·  Make-up for: Indicate the date of missed session within 2 weeks you are conducting make up for.

·  Session Cancelled: a) Check this off when the session is cancelled/not held. b) Indicate the date of the makeup session to be conducted (if appropriate).c) Describe the reason why below. (Note: no need for the following: CPT codes, activities, etc. Therapist signature is required. Caregiver signature is optional.)

·  ICD-9 Code: The relevant ICD-9 code as indicated on the child’s evaluation for your discipline. This is pre-written for your convenience at the time of your assignment. Please contact main office for more info.

·  CPT Codes: The relevant CPT (Current Procedural Terminology) codes as indicated by the interventionist’s professional association. IMPORTANT: CPT Codes MUST match its description & ICD-9 codes.

See IS form Therapy Monthly Log-Page 2 (i.e. list of suggested codes as per each discipline scope of practice). Check the time interval consistent w/each CPT code and list as many as you have conducted during the mandated session interval.

If conducted same CPT code several times indicate # of same CPT codes. Example: if mandate is Basic (A) –(i.e. 30 min & up) and same CPT codes was conducted 2 times (15 min each) please put: 1) CPT# 97530 X 2

• IFSP Outcome(s) Addressed: The target outcome(s) from the IFSP, which was/were the focus of that session’s intervention. These outcomes are taken directly from child’s current IFSP.(Note: this is the only section that can be pre-typed).

• Progress by child/family related to outcomes: Brief description of progress toward reaching the outcomes listed, including achievements and/or obstacles. Indicate if any IFSP objectives are met.

• Worked with parent/caregiver and child together…: Check the appropriate box indicating those involved in this session (child/family/caregiver)

• Activity During Session: Brief description of the intervention activities (at least 3) and child’s/family response to each activity during the session. These activities/descriptions MUST match CPT codes above.

• Activity with parent/caregiver: The activities done with the parent/caregiver. Check all that apply. Note that family needs are defined as anything that keeps the family from having the time, energy and focus to help meet IFSP outcomes (e.g. guidance on handling tantrums, etc.). In the activity section, please describe the family need and how it was addressed.

• List family activity for next week:

1. Indicate the one or more activities agreed upon by the interventionist and the parent/caregiver that will be used during daily routines in the coming week(s). Indicate: WHERE/WHEN/WHAT “homework” activities caregivers can do w/child during child’s daily routine.

2. If this session was a co-visit, list the family plan on the session note as agreed upon at the co-visit.

3. Indicate how the interventionist is helping the parent/caregiver document the activities to help his/her child during the daily routine. For example, if the objective is for the child to roll, the interventionist could write: “At bath or change time, the parent will use a towel or diaper to gently lift one side of the child to assist in beginning to roll.” Parent will record progress in parent/therapist notebook/calendar, etc.

4. Activities for parents are expected to span a minimum of one week. However, a therapist may see the child/family more than once per week; or activities may be recommended for multiple weeks.

Indicate in this section if you are continuing to work on an activity from the above Session Note.

3. Parent/Caregiver Signature and Relationship to Child: The parent/caregiver who was present during the session signs contemporaneously w/interventionist and indicates his/her relationship to the child (i.e. mother, babysitter, day care teacher, etc).

4. Provider’s Signature, Credentials License# : The interv-st’s signature full credentials (Ex: MA.CCC-SLP, #00921)

5. Keep the Session notes w/original signature in child’s file at the provider site. The Session notes may be reviewed or requested by the parents; therapist’s QA supervisor; NYC DOHMH EIP’s various departments such as the Regional Office and Program Monitoring and Quality Improvement; NYS DOH IPRO and OMIG.