This module focuses on the processes of documentation follow-up, and continuous quality improvement (CQI) after the plan itself is completed. It outlines the key elements necessary to include in a progress note, the practice of charting to the plan, and using the plan as an everyday part of the direct care work. It also focuses on promoting accountability and ongoing consumer satisfaction with person-centered care planning (PCCP) processes and service outcomes. It is intended to help practitioners, administrators, and supervisors to work collaboratively and effectively with individuals to evaluate both the process and the impact of PCCPs.

After completing this module, you will be able to:

• identify the key elements and the importance of a progress note in person-centered approaches;
  
• learn about different structures of writing a progress note;
  
• understand the value of utilizing the person-centered plan to guide everyday practice;
  
• understand the definition and benefits of concurrent documentation;
  
• identify strategies to solicit active service user involvement in ongoing CQI initiatives;
  
• identify workforce development needs and recovery-specific competencies.

A learning assessment is included at the end of the module. If you are already familiar with this subject, you may want to go to the end of this module and take the assessment to see how much you already know. Then you can focus your learning efforts on what is new for you.

Specific pieces of information are key to include in any progress note. These vary by organization and funder, but generally must include, at a minimum:

• Name of person and other identifying information (e.g., medical record number)
  
• Date of service
  
• Location
  
• Time involved (including the duration of service as well as the specific time that services were delivered)
  
• What services were provided
  
• Signature, including discipline, and supervisor co-signature if required

Notes must accurately reflect the activity, location, and time for each service. The time indicated within the note includes the time spent in travel to deliver the service, plan progress review for the next steps, the actual provision of the service, and the documenting of the service.

As part of a person’s medical, clinical, or health record, progress notes are considered legal documents. It is important that practitioners remain mindful of this status as they document their work and its impact. In addition to meetings with service users, practitioners need to document non-routine calls, missed sessions, and consultations with other professionals. Throughout, though, make sure that the focus is on the work being done and the person being served. Chart the person’s successes as well as any significant concerns you may have, particularly if the person is disconnecting from care and you have concerns regarding his or her welfare. Given that progress notes and the chart as a whole are a legal document, remember that these can be subpoenaed at any time.

You may have a note writing system that is prescribed by your agency. The following are several examples of structuring the progress note itself into key elements. Each has an acronym that represents the different content areas of the note.

The DAP (Description, Analysis, and Plan) note starts with a description of the important information observed along with interventions, followed by an assessment of the person and of his or her response to the interventions, and concluding with a plan for the next steps, including the staff’s next step, date of next contact, and any tasks for the person receiving services and his or her natural supporters.

A second format for the progress note is that of SOAP. SOAP notes start with the “subjective,” which includes what was said by the person receiving services, followed by “objective,” or what you observed as the practitioner. Next, similar to the DAP note, is the “assessment”: this is a description of the person’s response and any progress following the intervention, including specifically addressing the movement toward objectives and goals. This note also ends with the plan for the future, including the staff’s next step, date of next contact, and any tasks for the person receiving services and his or her natural supporters.

A third kind of progress note structure is the GIRPS (Goal, Intervention, Response, and Significant Observations). This is probably the most useful structure for writing billable progress notes for person-centered care approaches, as it includes the Goal and Objective aspect in the structure of the note. Continuously reflecting on these aspects of the plan serves as an important reminder of the person’s most valued recovery goal, and keeps the team collectively focused on working together to help them move forward toward this destination.

An organization may decide to use any of these structures to document the work and progress being made with a person in recovery. Regardless of what structure is utilized, it is important to include aspects of culture and context within the content of the note, as discussed in the next section.

When writing notes, technical elements are essential to include in addition to following whatever structure or format your agency or organization has decided to use. At the same time, the content of the note should not be overshadowed by the structure and technical detail. Without minimizing these aspects (as they are key to quality plan implementation as well as the billing and payment for services), we need to consider the language and other elements that should be considered in writing the note.

In terms of language, for example, as much of the progress note as possible should be written in everyday language so that the person receiving the services would be able to understand what has been recorded. Especially when concurrent documentation is being used (see below), it will be important for service users to review what is being recorded in their health record and be given an opportunity to provide their input on the content. Even when this is not the case, the language used in progress notes should mirror as much as possible the language used in the PCCP, which, as we suggested in Module 2, should be accessible to the person and his or her natural supporters.

We are not suggesting that diagnostic and clinical terms can never be used, however. What we are suggesting is that when it is necessary to use such terms, they should be accompanied by a description in everyday language of how what they are referring to is seen or experienced in the person’s everyday life. A common example of this would be describing the clinical phenomenon of “auditory hallucinations” as hearing the voices of significant figures in the person’s life, which may be either harsh and critical or supportive and helpful (or a combination of both). Other examples include describing “thought disorder” or “cognitive disruptions” as having difficulty keeping thoughts together or having difficulties with concentration, memory, or following the thread of a conversation. Similarly, “hypomania” can be described as increases in activity rates or levels, “dysthymia” as sadness, and “mood lability” as unexpected changes in the person’s moods over time. When framed in these ways, persons being served can learn to identify their difficulties, and signs of progress, taking on a more active and collaborative role in their own care.

Just as in the strength-based assessment and plan development, it is also important to consider cultural elements when composing progress notes. As every interaction represented the convergence of multiple cultures (e.g., the practitioner’s cultural identity and background, the service user’s cultural identity and background, the culture of the health care system), it is important as a practitioner to reflect these forces within the documentation of the note. This can include recording particular preferences and observations that are related directly to culture and referring to a person’s background and worldview and how these impact your assessment, interventions, and plan. Cultural factors should be considered along with the person’s own understanding of his or her situation and needs, especially to avoid viewing culturally influenced interpretations of these experiences as pathological. Seeing or hearing the voice of a deceased relative, for example, is considered a normal part of the grieving process in many cultures and does not always indicate the presence of hallucinations, which is understood as symptoms of an underlying illness. Important in this process is to be reflective about one’s own biases and to be aware of potential personal pitfalls.

To keep the plan an active and “living” document, useful in the everyday provision of services and working toward goals, it is important to update the plan regularly and as necessary. Typically, plans are required by regulators to reassess quarterly—every 90 days—and this is the national standard as well. A plan that is built on 90-day increments demonstrates belief in change as it communicates a hopeful expectation of progress and movement within a relatively short time frame.

Reviewing the plan is also key to evaluate the effectiveness of the interventions being provided at each meeting and subsequently to determine whether or not the plan itself needs to be revised. This is especially important if a new intervention is to be determined as needed. It also is the case that in order to bill for interventions, they need to be indicated on the plan. Therefore, as soon as possible, the plan should be revised to include new interventions and this, too, should be done as much as possible in consultation with the person receiving services.

Objectives may need to be revised if you realize that you and/or the person you are working with have been too ambitious and have bitten off more than what you can chew. An example would be a person who is interested in going back to college has set as an objective to “complete one college class with a grade of at least a ‘B’ in the next 90 days.” If in 3 weeks’ time, the person has yet to enroll or even pick up the phone to make a call to the registrar’s office, the goal will be too much of a step to start out with. This does not mean that the goal is unobtainable, but instead that you are presented with a chance to reevaluate the relative “size” of the objective with regard to where the person is now in his or her recovery. PCCPs should be designed as much as possible to build on successes; to do so, it is important to balance the high expectations of a recovery-oriented system (and of service users and families) with a realistic assessment of where the person is in his or her recovery at any given time, along with the resources he or she has at his or her disposal. It is possible, for example, that the person did not call the registrar because he or she cannot afford to enroll at that time. So when agreed-upon objectives appear to be out of reach, it may require both the practitioner and the person to scale back to more incremental steps that are achievable within the designated time frame. As described in Module 6, breaking long-term goals down into achievable, shorter-term objectives requires clinical skill and resourcefulness; the same is true of breaking ambitious objectives down into the intervening steps that need to be taken to get there.

Another possibility for the plan update is to consider adding or removing interventions as necessary and as the person’s condition evolves. To continue the above example regarding someone interested in returning to college, if the original set of interventions had not included a supported education component, it could be added to the plan so that a supported education counselor could support the person in making the transition into taking first a college class after a lengthy absence from academics.

The input of the person being served is essential in person-centered plan updates, just as it is in the initial development of the plan. When rewriting and reevaluating the plan on an interim basis (revisions between the full plan review), it is useful, as much as possible, to include natural supports and family members as desired by the service user. This may not be possible in all circumstances, but is something to work toward whenever possible. Finally, remember that reviews of the plan should not be triggered only by crisis events. In a recovery-oriented planning process, it is equally important to be future-focused and goal-oriented. Therefore, the team should reconvene around events of success/accomplishment as well as crises to revisit care plans and discuss next steps.

What we have described thus far is how an individual’s plan is to be reviewed and revised on an ongoing basis as his or her recovery unfolds over time. A parallel process can also take place at the agency or organizational level, as the process of care planning can itself become the object of review and revision as one focus of continuous quality improvement (CQI). It is to this topic that we turn next.