SCENARIO: You are meeting with Susie and her CLS/Respite caregiver, Joan, after school at the park in order to provide monitoring of services. Joan discussed a recent incident where Susie required an ER visit due to allergic reaction to a bee sting; she will now carry an Epipen on her at all times. Susie likes music and the color purple. Susie lives with her parents and goes to post-secondary school. Susie is working on goals in order to increase her independence; she eventually wants to move into an apartment with friends. Susie at times experiences anxiety and uses psychology services in order to develop coping skills, like deep breathing exercises and taking a break. Susie meets with her Support Coordinator or Support Coordinator Assistant at least 1x per month in order to review services and data related to goals/objectives she is working on with staff. Susie cannot be left alone due to seizure disorder; she experiences frequent seizures that are uncontrolled. Susie went to see her Neurologist last week; Joan tells you that she is on a new medication called Phenytoin. She takes it in the morning and at night.
write a brief progress note including any necessary follow up or information that is needed but not gathered during the visit.