Detroit Wayne Integrated Health Network Daily Progress Note IDD

Specialized Residential, Semi-independent Living, Self Determination, In-Home AMI

DWIHN Revision: 09/30/2019_SW

Consumer: MHWIN ID#: Date:

CRSP SC / CM: Facility: Specialized AFC SIL/SIP Self Determination In Home

Identified IPOS Goals: ____________________________________________________________________________

_____________________________________________________________________________ CLS Hrs: ______

_____________________________________________________________________________ PC Hrs: ______

_____________________________________________________________________________ Respite Hrs: ______

AM Mins PM Mins MN Mins Community Living Support CLS Objectives

C1 Medication Administration

C2 Grocery Shopping/Menu Planning/Meal Prep

C3 Laundry & Housekeeping

C4 Money Management

C5 Health Care/Dental Appt/ER Visit

C6 Community Outing/Religious Services

C7 Symptom Mngt/Redirection of Behaviors

C8 Socialization

C9 Transportation

C10 Health/Safety

C11 Monitoring/Protecting (sleeping)

Total CLS Mins: ______________ Personal Care PC Objectives

P1 Personal Hygiene

P2 Bathing

P3 Dressing

P4 Toileting

P5 Meds Management/Self-med Program

P6 Eating/Feeding

P7 Transferring (to bed, chair, & wheelchair)

P8 Ambulating

P9 Meal Preparation

P10 Special Laundry Needs

Respite Recipient Signature: ________________________________________________

Signature Required for Respite Service Only

Total PC Mins: ______________

Supervisory Signature: _______________________________________________ DATE: _________________

Consumer: MHWIN ID#: Date:

Detroit Wayne Integrated Health Network Daily Progress Note IDD

Specialized Residential, Semi-independent Living, Self Determination, In-Home AMI

DWIHN Revision: 09/30/2019_SW

TASK ID CODES H = Hospitalization M = Monitoring R = Refusal ED = Education/Day Program

TC = Total Care PA = Physical Assist VP = Verbal Prompts LOA = Leave of Absence HOH = Hand Over Hand I = Independent

PROGRESS CODES IP = Increased Progress DP = Decreased Progress SP = Same Progress

CLS/PC Task ID

Staff Action / Outcome:

Staff Initials

___________________________|__________ Staff Signature Credentials

_____________________________________ PRINT NAME

AM STAFF PM STAFF MN STAFF

Progress Code

CLS/PC Task ID

Staff Action / Outcome:

Staff Initials

___________________________|__________ Staff Signature Credentials

_____________________________________ PRINT NAME

AM STAFF PM STAFF MN STAFF

Progress Code

CLS/PC Task ID

Staff Action / Outcome:

Staff Initials

___________________________|__________ Staff Signature Credentials

_____________________________________ PRINT NAME

AM STAFF PM STAFF MN STAFF

Progress Code

CLS/PC Task ID

Staff Action / Outcome:

Staff Initials

___________________________|__________ Staff Signature Credentials

_____________________________________ PRINT NAME

AM STAFF PM STAFF MN STAFF

Progress Code