Follow the steps to successfully complete the Shift/Daily Progress Note

1. Press the ‘Get Form’ button to access the form and open it in your document editor.
2. Begin with the identifying information section. Enter the person’s full name, including first name, last name, and middle initial, in the designated fields. Next, record your agency's identification number and the person’s date of birth for accurate identification.
3. For the organization name, write the name of the organization you represent when delivering the service.
4. Indicate the type of program being documented by checking the appropriate box. Choose from options such as Crisis Stabilization Unit, Detox, or Respite Bed.
5. Select the appropriate shift note type. Depending on the time frame you are documenting, check either the Shift Note box or the Daily Note box.
6. Document any new issues presented today. If no new issues are reported, mark 'None Reported.' If issues are resolved during the shift, note them accordingly or indicate if further assessment is required.
7. List the goals and objectives that were addressed as per the Individualized Action Plan. You may check the corresponding boxes or write down the specific goals being addressed.
8. In the functioning section, provide observations regarding the person’s behavior and interactions during the period of the note. Ensure the information encompasses both self-reports and observational data.
9. Outline the therapeutic interventions provided during the shift. Describe the specific techniques and methods utilized to assist the individual in achieving their goals.
10. Assess the person’s response to interventions and track their progress toward goals and objectives. Ensure to include any shifts in their condition and how they responded to the therapeutic efforts.
11. In the plan/additional information section, discuss any planned strategies for the following shift based on the individual's progress or lack thereof. Document additional pertinent details that are relevant.
12. Complete the signature section by legibly printing your name, title, and credentials. If required, a supervisor should also sign and print their name.
13. Lastly, complete the billing strip by providing the date of service, provider number, location code, procedure code, modifiers, start time, stop time, total time, and the diagnostic code, as necessary.

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