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Service Note Details
Client
Frederick (Tom) Walker, Jr.
Created By
chharris128@gmail.com
Created
2022-07-03
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
TW was awake when I arrived on duty. I was briefed by staff about events of the previous shift. House is secure, TW is in sharing about his week. TW stayed up until about 2:17am watching Obi Won Kenobi. He proceeded to go to bed at that time. He was in good spirits. House temp. Was 67° ,TW expressed that he was cold ,so I adjusted the thermostat to 74°.
Start Time
11:00 PM
End Time
Time Duration
Signature
Service Notes_Images/94920.Signature.095755.png
Geolocation
40.262163, -75.588559
Signature
Record Status
Active