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Service Note Details
Client
Frederick (Tom) Walker, Jr.
Created By
cldpulley@gmail.com
Created
2022-06-20
Care Instruction
Supervision Outcome Statement: Supervision Outcome Statement:
PROACTIVE STRATEGIES:
. THOSE WHO SUPPORT TOM SHOULD PROVIDE HIM WITH DETAILS OF ACTIVITIES THAT WILL OCCUR DURING THAT SHIFT
. THOSE WHO SUPPORT TOM SHOULD VISIT PLACES HE ENJOYS.
(APPROVED OUTINGS ONLY CALL )
. TOM ENJOYS A CALM, QUIET ENVIRONMENT TO HELP WITH ANXIOUS BEHAVIORS OR THOUGHTS.
. HE RESPONDS BETTER WHEN STAFF SPEAK TO HIM IN A SLOW, CALM VOICE AND MAKE EYE CONTACT
. OFFER CHOICES OF HIS FAVORITE ACTIVITIES
. ENCOURAGE TOM TO KEEP A CONSISTENT DAILY ROUTINE ALLOW FREE TIME
. OFFER OPPORTUNITIES TO ASSIST IN CLEANING OF THE HOUSE TO FEEL THAT HE HAS CONTRIBUTED NO MORE THAT 3 OPTIONS TO HELP BUILD INDEPENDENC
. THOSE WHO SUPPORT TOM SHOULD HAVE A BACKGROUND KNOWLEDGE OF HIM
. WHEN MEETING TOM FOR THE FIRST TIME, THOSE WHO SUPPORT HIM SHOULD TAKE THE TIME TO EXPLAIN WHO THEY ARE AND BUILD RAPPORT.
COMMUNICATION:
. WHEN IT APPEARS THAT TOM WANTS TO OBTAIN AN ACTIVITY OR ITEM ENSURE HE UNDERSTANDS THE ANSWER BY REPEATING THE ANSWER.
. HELP TOM WITH ACCEPTING THE CONCEPT OF TWO-SIDED CONVERSATIONS.
REACTIVE/DE-ESCALATION STRATEGIES:
. SUGGEST TOM TAKES A WALK, WEATHER PERMITTING
. ASK TOM IF THERE IS A MOVIE HE WOULD ENJOY WATCHING
. REMINDERS OF WHAT ACTIVITIES ARE COMING UP THAT HE WILL ENJOY
THINGS TO AVOID/AND OR TRIGGERS:
. NOT HAVING HIS QUIET TIME AVAILABLE
- DRINKING HOT COFFEE IN THE KITCHEN (PLEASE ONLY DRINK IT IN THE STAFF OFFICE)
. LOUD NOISES AND BUSY CROWDS
. INSISTING THAT HE HAS TO COMPLETE A NEW TASK, OR NON-PREFERRED TASK.
Outcomes
-Tom will work with staff to document upcoming appointments by adding the appointments to the day planner with no more than 2 prompts from staff.
-Tom will contact the Program manager/Program Director by email or voicemail or to request transportation at least 24 hours in advance of the scheduled appointment with no more than 2 prompts from staff.
-Tom will further develop his social boundaries and appropriateness skills by increasing his ability to take turns with others during conversations with no more than 2 prompts to stop speaking and listen to the other speaker.
Service Note Entry
Tom was out with his mother when I arrived. He came back shortly after 1pm. He told me he tried to go to the bank but it was closed due to the Juneteenth holiday. His leg was swollen, red and very shiny. I encouraged him to go to the doctor or ER for treatment but he declined. His mother also encouraged him to seek treatment earlier in the day. He napped on the couch and waited for the Rifleman to come on at 3pm. He was still on the couch when I was relieved at 3pm.
Start Time
01:00 PM
End Time
Time Duration
Signature
Service Notes_Images/23172.Signature.024124.png
Geolocation
40.177283, -75.547531
Signature
Record Status
Active