Goals: Write in all goals/criteria, numbering each goal.	Month/Year	SEPTEMBER 2011
Days Covered	16-30
1. XYZ wants to have help with going to his medical appointments by marking them on his calendar, waking up on time, and being on time to his appointments when needed with help. (SLC)

2. XYZ wants to have help with preparing dinner by planning for, buying groceries for, and preparing meals once a week with help. (SLC)

3. XYZ wants to have a good time and spend money whenever he wants to. (XYZ)

4. XYZ wants to save his money for a new fishing rod by making a budget, modifying it when needed, and putting some money in his Piggy Bank after he pays his bills at least once a week with help. (SLC)

Contact: Write date, mark an X if the client was not home, accomplished a typical routine, if you did overnight monitoring. Enter wake up/bedtime. Mark an X if discussions or activities occur for Topic Addressed (rights, responsibilities, HIPAA, choice, social inclusion, security, social roles, dignity, respect, health, safety, abuse, conflicts, satisfaction, etc), if appointments or quarterlies occur, and if goals are addressed. Enter staff time in-time out, # of clients worked with, and hours or days (NOT both). Quarter hours and totals calculate automatically.
Date (mm/dd/yy)	9/26/11	9/27/11	9/30/11
Topic Addressed	x
Health Appt	x
Quarterly	x
Goal Addressed	x	x	x
Time In-Time Out

7:30a-10a	9a-11a	10-11
# Clients	1	1	1
HOURS	2 .50	2 .00	1 .00
QUARTER HOURS	10 .00	8 .00	4 .00	0 .00	0 .00	0 .00	0 .00
TOTAL HOURS	5 .50
TOTAL QUARTER HOURS	22 .00
Date	Notes: Summarize topics addressed, appointments, activities, and any non-goal related areas worked on. Areas marked under Contact must match notes. Describe work on each goal: describe the client's progress on each goal (by number) including how the client worked on each goal, what staff did to help, and what was accomplished towards progress on the goal. State what's next.
9/26/11	I accompanied XYX to Quest lab for fasting bloodwork and assisted him with registering and answering questions about his fasting. I accompanied XYZ to have breakfast and assisted him with ordering and figuring out the tip for his meal. I assisted XYZ with preparing his lunch and with washing his dishes from last night and drying them and putting them away. I asked XYZ what he had planned for tomorrow and he said he was going to go to the library with a friend.

1-XYZ was able to independently get up in time to go to his bloodwork appointment. I assisted him with marking the appointment on his calendar last week and called to remind him of his appointment yesterday evening. I picked him up at the agreed on time and accompanied him to his appointment where he had his fasting bloodwork. I praised XYX for getting up in time for his appointment.

2-XYZ had taken out hamburger to thaw yesterday after looking at his menu on his calendar. He said he wanted to make spaghetti sauce and we had purchased the needed ingredients last week. I assisted him with cooking the meat until he decided it was done and was able to tell me how he knew it was done (no pink). He opened a jar of pre-made sauce and added that to the meat and stirred it. I suggested he let this simmer to develop the flavors and he liked that idea. I assisted him with cutting up an apple to have with his dinner and he used the corer/slicer with my help placing it and pressing down on the apple. He laughed, ate a slice, and put the rest in the refrigerator for dinner.	Jane Doe
9/27/11	XYZ did ..... I assisted XYX with .....

I asked XYZ what he had planned for tomorrow and he said he didn't know yet.

1-XYZ blah, blah, blah.... vacuuming....

2-XYZ checked his calendar for his menu today with a reminder and also decided on his menu for the rest of the week. He prepared fish sticks and tater tots in the oven. I assisted him with going over the directions on the package, setting the oven temperature, and figuring out how many sticks and tots made up 1 serving. He sprayed the pan with oil and laid out the fish and tots and set the digital timer with help on counting. He had leftover fruit and vegetables which he decided were ok to have with his fish and tots and I helped him with the serving amount. He used his bowl to measure 1 serving and then put the food on his plate.	JD
9/30/11	XYZ did blah, blah, blah. I assisted XYZ with .... XYZ asked me about whether he needed to contribute a part of the rent every month and whether he could sometimes just save that money. We talked about responsibilities and I asked him how he would feel and what would happen if his 2 roommates decided to "just save their money" too instead of paying rent every month. He laughed and said that wouldn't work and said he hadn't thought of it that way. XYZ had his Quarterly 2 meeting with his WSC, me, and his IHSS. We went over blah, blah, blah during his meeting.

I asked XYZ what he wanted to do next time and he said "blah, blah, blah."

4-XYZ blah, blah, blah.	Jane Doe
End of Month Summary: Write a summary of topics addressed, appointments, activities, and any non-goal related areas worked on during the month. Write a summary of goal progress: describe how the client progressed on each goal (by number), what the client accomplished, what the staff did to help the client accomplish the goal, what activities were achieved, whether the client was satisfied with activities, and whether the goal needs to be continued or changed.
This month, XYZ did blah, blah, blah. We discussed a variety of topics including blah, blah, blah. He had a fasting bloodwork appointment, saw his primary doctor for a follow up visit to his bloodwork which was all within normal limits, went to the grocery store and the bank, and went to the library with a friend. XYZ also discussed responsibilities, rights, and social roles with me this month. XYZ also had a Quarterly 2 meeting with his WSC, IHSS, and SLC present.

XYZ worked on two of his goals this month.

1-XYZ marked his medical appointments on his calendar with help identifying the days and was able to get himself up in time for his two medical appointments with only a phone call from me to remind him about his appointments the night before.

2-XYZ was able to plan 4 meals for the month, marking them on his calendar, going shopping for ingredients, and then preparing his meals with staff assistance. He needed help with coming up with ideas for meals, marking his meals on the calendar, shopping, and preparing the meals. He is able to complete meals with assistance, needing help with staying on task and making sure he completes one thing before going on to the next. We discussed going to the library to find some cookbooks and he is excited about this and talks about it a lot. At the beginning of next month, he is looking forward to putting his meal plans on the calendar with my help.

XYZ said he is interested in trying out blah, blah, blah next month and also said that he wants to blah, blah, blah....	Jane Doe