Requirements for documentation of early intervention (EI) services is different from documentation in other practice settings. In many ways, documenting EI services is easier, but an EI practitioner should know the key differences of how and what to document.
6 Tips for HOW to Document:
Write your daily session notes and monthly progress reports in parent-friendly language. Avoid jargon and professional/medical abbreviations. Ensuring that your documentation is in a language the family understands empowers the family to be more involved in EI services, leading to better outcomes. The average reading level in the United States is below the 8th grade level; therefore, EI documentation should be written at a 5th-6th grade reading level. One way to ensure you are writing in the parent’s readability is to allow the parent to be involved while you write the note at end of session.
The Individualized Family Service Plan (IFSP) is the legal document that you must follow. This means all services should follow the IFSP exactly. For example, intervention goals you include on the daily session notes should match the goals listed on the IFSP. Once goals are met or need to be changed, the IFSP must be updated first. Changes, updates, and additions to the IFSP are typically made at quarterly meetings, six-month reviews, and annual meetings. Be sure to attend those meetings if you want any input on how the IFSP is written.
Point of Service Documentation: In the EI setting, documentation should occur at the end of the session in the presence of the family – use this time to coach and educate the family and facilitate discussion with the caregiver about how the child performed in the session. Turn this “documentation time” into a conversation. Keeping the caregivers involved with documentation will help them feel included in the daily session and planning of the next session. Documentation time is an excellent opportunity to ensure the family “buys in” to the service you are providing. Engaging the caregiver/family in the documentation process aligns with the EI principle of providing family-centered care.
Write objectively: Make sure that your documentation does not reflect any negative feelings or reactions that you have toward the child or family members. Avoid terms and descriptions that seem judgmental. Use proper grammar and proper sentence structure so others can understand what you are documenting.
Write with ‘People-First’ language: When describing a child and referencing their disability, identify the child first and the illness/disability should be used as a secondary descriptor. The illness/disability should not be the primary identity of a child or person.
When documenting on forms, be sure to complete ALL fields on the form. This ensures you document all required information and protects you in case of an audit.
6 Tips for WHAT to Document:
Document your observations of what the child did in this session that was unique or different from previous sessions.
Describe how the child’s environment was changed or how the activity/intervention was modified to support the child’s participation and success with the activity.
Document the child’s progress towards the goal(s), and how you facilitated that progress with the session activities. When possible, write objective measurements that demonstrate progress toward the goals/outcomes.
Document any education you provided to the family and how you coached the caregiver to promote the child’s participation in everyday family routines.
Describe how the caregiver participated in the session and include what the caregiver reports for how the child is progressing with a particular goal/activity and during their daily routines.
Document your observations: i.e., the child’s appearance, behaviors, and interests. Also relevant is how the child interacts with you/others and the child’s mood.
All EI documentation must be maintained for five years after the child is no longer provided services through the early intervention program.