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Annotated Guidance for Writing EI Session Notes

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Annotated Guidance for Writing EI Session Notes

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OCDEL Announcement EI 23-01 Early Intervention Session Note

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OCDEL Announcement EI 23-01 Early Intervention Session Note

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Purpose

The purpose of this announcement is to notify Infant Toddler Early Intervention (EI) programs of a new session note format. Announcement EI-13 #03 becomes obsolete on the effective date of this announcement.

Background

The Office of Child Development and Early Learning (OCDEL) developed a standardized session note format to be used by all Infant Toddler EI programs in response to requests for a statewide process. The session note reflects the Key Principles of Early Intervention in PA. It documents the provision of services and supports, assures communication with families or caregivers, and provides a mechanism to monitor the progress toward the Individualized Family Service Plan (IFSP) outcomes/goals.

Discussion

The session note is a record of the service provided to the child and family or caregiver by the EI service provider. It includes information related to how the service assists the child and family or caregiver to achieve the IFSP outcome and the progress being made on session targets to support the IFSP outcome. It also includes a summary of the family's plan to embed strategies between sessions. The information in the session notes is also a resource for team members as they work together toward achieving the outcome for the child and family.

A session note must be completed by an EI professional when IFSP services are delivered to a child. A copy of the session note, either paper or electronic, must be given to the family and/or caregiver at the end of the session or within a reasonable amount of time so the family plan for between sessions can be utilized. If services are delivered in an early care and education environment, a copy should be provided to both the family and the caregiver at the early care and education program. When a planned service delivery does not occur (i.e., child or EI professional is absent, cancellation without notice, or an act of nature) the EI professional shall document this occurrence including the reason.

The session note needs to be written in a professional, accurate, and unbiased manner without acronyms or jargon. It shall be written legibly and in an objective format and not include personal feelings, beliefs, judgments, or assumptions. This is to ensure it also serves as a resource to the family, caregivers, other team members, and service providers. If service is provided by someone who requires supervision under their scope of practice, then there must be a supervisory signature on the session note (indicating that appropriate supervision was performed according to applicable standards). The session note format, along with annotated guidance for completion of each section of the session note can be found at PaTTAN. A job aid with additional resources is also available at Early Intervention Technical Assistance Portal.

The session note serves as one of the important components of on-going progress monitoring so that the service provider can review and revise strategies. A review and analysis of session notes, along with other data collection and progress indicators, provides the basis for documentation of progress that supports the requirement for ongoing progress monitoring of the IFSP outcomes.

Next Steps

1. Infant Toddler EI Coordinators shall review current practices and revise any local procedures to ensure the guidance in this announcement is implemented.

2. Infant Toddler EI Programs should contact Early Intervention Technical Assistance for additional copies of the no carbon required (NCR) version of the standardized session note.

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EI 23-01 - Early Intervention Session Note

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Announcement Number: EI 23-01 Issue Date: 06/28/2023 Effective Date: 07/01/2023 Audience: Infant Toddler Early Intervention Programs