PCA Example Progress Note Entries

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PCA EXAMPLE PROGRESS NOTE ENTRIES
ACCEPTABLE
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Accompanying students on school buses or other vehicles. A PCA s presence is necessary
because of a student s physical disability or mental health disability.
o Escorted Hannah to the bus for a field trip. She required monitoring on the bus to stay
in her seat and keep her seat belt buckled.
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Activities of daily living such as eating; grooming; bathing; toileting; etc.
o Took Mike to the bathroom. He required direct PCA assistance to pull down his pants
and sit on the toilet. He was not responsive to verbal prompts. Mike required
redirection to stay sitting on the toilet while going to the bathroom. Mike followed
prompts from PCA to wash his hands.
o Monitored Monica when she used the bathroom. She was able to complete all necessary
bathroom tasks with minimal prompting.
o Christian required hand over hand assistance to wash his hands before snack.
o Assisted Xavier with completing his morning hygiene routine of brushing his teeth,
combing his hair and washing his hands. Xavier completed 18/52 steps on his own.
Xavier required prompts for continuation of steps and attention to task.
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Assisting the student to ambulate; position; and transfer.
o Monitored Christian for safety while walking in the hallway between classes. Assisted
Christian in opening his locker. Required to prompts to walk and not run.
o Assisted Hannah using hand over hand prompts to transfer from her wheel chair to her
desk.
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Assisting the student to use and maintain augmentative communication devices.
o Assisted Terri in using an ipad to communicate what she wanted for snack. She
required hand over hand prompts to put her finger on the appropriate icon.
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Assisting the student to use equipment.
o Assisted Carl to use the computer to type an assignment. He required verbal directives
to use the mouse and keyboard appropriately.
o John required verbal directives to appropriately use ipad during reinforcement time.
John was receptive to directives when given.
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Assisting; monitoring; and guiding the student to pay attention; participate in activities; and
complete tasks.
o Repeated teacher directives/directions given to class individually to Christian. Brokedown directions into 3 smaller steps. Christian required minor prompts to complete the
assigned task.
o Reminded student to remain attentive and focused during class. Monitored student
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through the remainder of class to ensure participation and attention to task.
Escorted Tracey through the lunch line. She required hand over hand assistance to hold
her tray and verbal prompts to identify what she wanted to eat. Needed redirection 3
times to eat her food and not play with it. Monitored her for safety throughout the
lunch period.
Christian required prompts to participate in gym class after PCA observed student
sitting on the floor. Required continued prompts throughout the class to stay focused
and on task.
Escorted Danielle out of the school during a fire-drill. Danielle required prompts to
follow proper safety skills. Monitored Danielle during time outside while awaiting
further instructions.
Sarah required redirection to not talk during class.
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Hands-on assistance; cueing; or supervision of medical/mental health-related services
provided by the PCA under the direct (on-site) supervision of the professional nurse.
Activities may include catherizations; suctioning; oxygen admin; and tube feedings.
o Escorted John to the nurse to receive daily medication. Required prompts to walk in the
hallway. John needed verbal redirection to follow nurses’ directives.
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Monitoring the incidence and prevalence of designated health problems or medical
conditions; e.g.; seizure precautions or extreme lethargy.
o Monitored Alex during free time. He seemed very tired and lethargic. He was not
responsive to prompts from PCA and did not interact with peers when prompted to do
so.
o Christian verbally indicated that he did not feel well. Christian put his head down on
the desk to rest. PCA monitored Christian for health related side effects.
o PCA noticed that Lindsey had difficulty focusing. PCA moved her to a safe area due to
her prevalence of seizures. PCA monitored her as a precaution.
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Observing and intervening to redirect inappropriate behavior.
o Jose was aggressive towards PCA when he did not get to pick his desired snack. PCA
used planned ignoring and redirected Jose to keep his hands to self.
o Monitored Michael for safety while on the playground. Redirected Michael for
inappropriate playground behavior 2 times. Michael was receptive to redirection.
o Christian required constant redirection during a speech session for attention to task.
Christian attempted to get out of his desk multiple times and seemed to have difficulty
focusing. Christian was receptive to redirection for only a short period of time before
requiring additional prompts.
o Jane required redirection to keep her hands to self. She was not responsive to
redirection and required hand over hand prompts to keep her hands on her desk. Jane
continued to attempt to pinch and grab PCA. PCA prompted Jane to use a coping skill
to calm down. PCA verbally prompted Jane to count to 10.
o Christian attempted to elope from the classroom. PCA redirected Christian back to the
room.
o Met Luna at the bus upon arrival at school. Required hand over hand prompts to put on
her shoes and socks. Required redirection after attempting to elope.
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Range of motion and other exercises.
o PCA took George on an exercise walk with peers. He required constant monitoring for
safety throughout the walk. George required redirection multiple times to walk on the
sidewalk and stay with the group.
UNACCEPTABLE
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Yelled at Johnny for not listening to directions. He listened after that.
Read test question to Cindy and wrote down her answers that she gave verbally.
Hung up Mary’s jacket in locker and put her book bag away.
Prepared Mary’s snack that mom sent in.
Helped Beth write her history essay during study hall. She was having trouble thinking of a
topic to write about.
Watched Mary eat her lunch with peers. She sat at the table and threw her tray away when she
was finished.
Christian put on deodorant and washed his hands.
John switched classes.
During English class Mary read Romeo and Juliet with the class.
Mike required redirection for getting a math problem wrong.
Christian used the bathroom between classes.
Joe went on a class field trip for the entire days. She liked the animals at the zoo. She was quiet
on the bus.
8:00am-2:00pm ~ Met Justin at the bus drop-off. Helped him at his locker. Walked him to class.
Redirected him for attention to task during math. Monitored for safety during lunch. Took him
to the bathroom. Prompted him for participation in class. Walked him to the bus pick-up zone.
He had a good day.
Alyssa required redirection during math class because she kept talking to her friend Susie.
They were talking about the new Justin Beiber song “Baby”. Alyssa really likes that song so
she was distracted. I redirected her for attention to task. Alyssa told me that she had a difficult
time focusing because she likes Justin Bieber so much and wants to marry him. I reminded her
that she was in class and needed to focus on school work. Alyssa completed a math problem
with continuous prompts to stay focused and attentive. She got the problem right.
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