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- NYC EIP Session Note 8 2014 - V 1 (City of New York)

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Child’s Name: __________________________________________________DOB: _____/_____/______ Sex:  Male  Female EI #: __________________________
Interventionist’s Name: ______________________________Credentials: _________________National Provider ID #: __________________ Service Type: _____________
Session Date: ____/____/____ IFSP Service Location: __________________________
Time: From _______________  AM  PM To __________________ AM  PM
Session Date: ____/____/____IFSP Service Location: ___________________________
Time: From _______________  AM  PM To __________________ AM  PM
Date Note Written: ____/____/____ ICD-10 code: _____________________________
HCPCS Code (if applicable):____________________ 1st CPT Code: ______________
2nd CPT Code: _________ 3rd CPT Code: __________ 4th CPT Code: _________
Date Note Written: ____/____/____ ICD-10 code: _____________________________
HCPCS Code (if applicable):____________________ 1st CPT Code: ______________
2nd CPT Code: _________ 3rd CPT Code: __________ 4th CPT Code: _________
Session cancelled - reason listed in #1. Session must be made up by: ____/____/____
This is a make-up for a missed session on ____/____/____. (must be within 2 weeks)
Session Participants: child parent/caregiver Other: _______________________
If the parent/caregiver was unavailable, how did you communicate with them about the
session?
Session cancelled- reason listed in #1. Session must be made up by: ____/____/____
This is a make-up for a missed session on ____/____/____.(must be within 2 weeks)
Session Participants: child parent/caregiver Other: _______________________
If the parent/caregiver was unavailable, how did you communicate with them about the
session?
1. Describe the progress that the child has made toward the IFSP outcomes since the
last session. Include parent/caregiver feedback.
1. Describe the progress that the child has made toward the IFSP outcomes since the
last session. Include parent/caregiver feedback.
Additional information about the session (as appropriate): Additional Information about the session (as appropriate):
2. IFSP Functional Outcome(s) and Objective(s) addressed during this session: IFSP Functional Outcome(s) and Objective(s) addressed during this session:
3. Routine Activities worked on during the session: Activities of Daily Living (ADL)
 Play/Social  Community/Errand  Other(s):______________________________
Strategies used within the Routine Activities: Modeling  Cues  Prompts
 Positioning  Assistive Technology  Other:
3. Routine Activities worked on during the session:  Activities of Daily Living (ADL)
 Play/Social  Community/Errand  Other(s):______________________________
Strategies used within the Routine Activities:  Modeling  Cues  Prompts
 Positioning  Assistive Tech  Other:
4. How did you work with the parent/caregiver?  Observed parent/caregiver and child
during routines  Parent/caregiver tried activity, feedback exchanged  Demonstrated
activity to parent/caregiver  Reviewed communication tool with parent/caregiver
 Other:_______________________________________________________________
4. How did you work with the parent/caregiver? Observed parent/caregiver and child
during routines  Parent/caregiver tried activity, feedback exchanged Demonstrated
activity to parent/caregiver Reviewed communication tool with parent/caregiver
 Other:_______________________________________________________________
5. What strategies/activities did you and the parent/caregiver collaboratively agree to
do to support their child’s learning and development between visits?
5. What strategies/activities did you and the parent/caregiver collaboratively agree to do
to support their child’s learning and development between visits?
Parent/Caregiver Signature: ______________________________Date: ____/____/____
Relationship to child: _____________________________________________________
Parent/Caregiver Signature: ______________________________Date: ____/____/____
Relationship to child: _____________________________________________________
Interventionist Signature: _______________________________Date: ____/____/____
License/Certification #:___________________________________________________
Interventionist Signature: _______________________________Date: ____/____/____
License/Certification #: ___________________________________________________
NYC Earl
y
Intervention Pro
g
ram Session Note 9
/
2015 Version 1
–
Two Notes Per Pa
g
e
NYC Early Intervention Session Note Instructions 9/2015
NYC EARLY INTERVENTION PROGRAM
INSTRUCTIONS FOR COMPLETION
SESSION NOTES
GENERAL DIRECTIONS
The interventionist must complete this form for each session completed and document whenever a session is cancelled and the
reason for the cancellation on the form. The family should receive a copy of the session note as close as possible to the completed
session. A copy must also be submitted to the interventionist’s provider agency for billing purposes. All Session Note fields are
mandatory. A provider may add additional fields to the form if necessary. Refer to the Session Note Policy
DEMOGRAPHIC/AUTHORIZATION INFORMATION
Child’s Name:
Information must be the same as in NYEIS (do not use nickname).
DOB:
Enter child’s date of birth.
Sex:
Enter the sex of the child (M, F)
EI #:
The EI # appears at the top of the “Child Homepage” in NYEIS
Interventionist Name:
Print the name of the interventionist who is completing this form.
Credentials:
Interventionist’s discipline/credentials, e.g. speech therapist (Speech/Language Pathologist, MS,
CCC/SP, special educator (MS Ed.), etc.
National Provider ID (NPI):
Write the National Provider ID (NPI). [See NY State regulations from June 2010.]
Service Type:
IFSP authorized service delivered by the interventionist, e.g. Speech, Physical Therapy
Session Date
Date session was held.
IFSP Service Location:
This is the location the IFSP indicates the service is to be provided (i.e., facility, etc.).
Date note written:
Date that the interventionist completes the note. It is expected that notes are written
contemporaneously or as close as possible to the session.
Time:
Exact duration of session. From begin time to end time. AM/PM must be indicated in order to
support billing.
ICD-10 code *
The relevant ICD-10 code as indicated on the child’s evaluation (effective 10/1/2015).
HCPCS Code (if applicable) Enter the Level II HCPCS code for the service or product provided by a non-health care
interventionist (for example, Special Educator).
CPT Code(s)
Enter the CPT code(s) as indicated by the interventionist’s professional association.
Depending on the CPT code, a session may require that more than one. For example, if
the same service was provided for a 30 minute session and the CPT code is for 15
minutes of service, the CPT code would be listed twice. (See Early Intervention
Memorandum 2003-1).
Session Cancelled:
When a session is cancelled:
1. Indicate that the session was cancelled and document the reason under question #1.
2. The missed session must be made up before: Write the date that is 2 weeks from the
missed session. The make-up session should occur prior to this date.
3. This is a make-up session for: If this session is a make-up session, check this box and
indicate the
date of the mi
ssed session.
Note: Refer to the Make-Up Policy
Session Participants
Check the box that indicates the session participants. Specify others not listed (e.g., siblings).
If the parent/caregiver was
unavailable, how did you
communicate with them
about the session?
Indicate the method(s) used to communicate strategies to the parent/caregiver when they are not
available. Consistent communication and collaboration with families and with the EI team are
essential in early intervention services.
Communication with the family and other EI professionals is important for teaming and
collaboration. Document briefly the strategies that were used to work with the ch
ild
when the parent/caregiver was not available or chose not to participate in the session.
Interventionists may refer to their documentation in questions #3 and #5 when this is the
information they communicated.
Parents decide how they want to communicate with their EI team whether they are
receiving services at home, at a center-based program, at a facility, and at a day care
center. Different types of methods include a communication book, videos, phone calls,
the voluntary NYC EIP Family Activity Sheet, etc. If parents want to use ema
ils, please
see the NYS DOH BEI Policy and Parent Consent to use emails.
*
Visit
https://support.eibilling.com/Main/Default.aspx for detailed guidance on ICD-9 to ICD-10 converstion
NYC Early Intervention Session Note Instructions 9/2015
Questions #1 to #5 support the interventionist in their work with the parent/caregiver and the child. Below is a diagram to
visually show what kind of information is to be covered. (Refer to the Appendix for definitions of terms.)
1. Describe the
progress/
responses th
at
the child has made toward
the IFSP outcomes since
the last session.
Include
parent/caregiver feedback.
Additional information about
the session (as
appropriate)
The information in this section guides what will be worked on during the current session.
In this section, the interventionist must document:
1. The progress the child has made since the last visit (e.g., generalization to other routin
es,
ease of doing, obstacles encountered) after observing the child and parent/caregiver in the
routine and discussing it with the parent/caregiver.
2. Document feedback from the parent/caregiver as to what strategies worked and did not
work.
Document any other information about activities that took place during the session. This may
include the following:
Updated information about the child/family if there are changes in medical or developmental
status or in community services; indication of whether parent/caregiver is interested in attempting
new functional outcomes or strategies.
Any other information about the session the interventionist wants to record
.
2. IFSP Functional
Outcome(s) and
Objective(s) addressed
during this session:
Document the IFSP functional outcome(s) and objective(s) that was worked on in this session
with the child and parent/caregiver.
Interventionists should address the IFSP functional outcomes and objectives based on
their own scope of practice proficiency, knowledge and experience.
Whenever interventionists believe that they cannot address an IFSP functional outcome
or objective, they should document this in Question #1 in the NYC EIP Progress Note
with an explanation.
Note: Ongoing discussion with the parent/caregivers abou
t what their concerns, priorities and
resources currently are will help guide the functional outcome or objective that will be worked on
during the sessions and promote collaboration with families.
3. Routine Activities worked
on during the session:
The session note must include documentation that services are being delivered within the context
of the family’s natural routines and are functional for the child.
1. The routines must be specific to the family’s cultural and social environment and are
of a
concern and priority for them.
2. The routine activities should include but are not limited to those listed in the functional
o
utcomes in
the IFSP.
3. It is expected that a range of family routines be documented when appropriate. Routines
should not be limited to “play routines”.
Check off all those routine activities that were us
ed during the session, or write in the daily
routine if it is not listed. Routine activities may include:
Activities of Daily Living (ADL) Routines which cover hygiene routines, food
routines, and dressing routin
es;
Play/Socialization routines,
Community/Family routines;
Learning
Activities to
do until the
next visit
Observation
of child &
parent in
routine
activities
Functional
Outcomes
Agree and
review
strategies
within the
routine
activities
Feedback
from parent
Coach parent
on strategies
that fit the
child and
family best
.
NYC Early Intervention Session Note Instructions 9/2015
Strategies used within the
Routine Activities:
Song/Rhyme Routines; and
Book Routines.
Note: Interventionists should work collaboratively with family to seek opportunities to adapt
learning experiences and therapeutic strategies to reflect the individual characteristics of the child
and family, and to identify and implement, as appropriate, strategies that enhance and promote the
child’s participation in natural learning opportunities across both child and family routines and
community settings [ (NYS DOH Provider Agreement XII C4).
Indicate which strategies were used to help the families/caregivers successfully support
their children’s participation in daily activities.
The following are examples of strategies:
Positive reinforcement at all levels;
Parent models, child imitates;
Verbal cues only;
Gesture with verbal cues;
Physical prompts;
Hand-over-hand;
Increased opportunities to practice;
Modification of the social or the physical environment;
Positioning;
Adaptation of materials;
Use of Assistive Technology; and
Discrete trial instruction.
4. How did you work with
the parent/caregiver?
Each family learns in different ways. Some families may not choose to participate in a session
while others may choose to participate. Check off all techniques used during the session. If a
technique was used that is not listed, please check “other” and describe the technique(s).
Some techniques that can be utilized with the parent/caregiver include, but are not limited to:
Observed parent/caregiver and child performing activ
ities;
Discussed activity with parent/caregiver;
Assisted pa
rent/caregiver
;
Gave the parent/caregiver a picture illustrating the way to position the child after
demonstrating the method;
Demonstrated parent/caregiver-child activity while describing and explaining what
was happening;
Modeled and explained a strategy and provided feedback as parent/caregiver tried
the activity with the child;
Vi
deotaped learning activity and rev
iewed with parent/caregiver;
Observed parent/caregiver and child performing activities, with both the
parent/caregiver and the interventionist providing feedback during the session;
Reviewed communication tool with parent/caregiver;
Identified the methods and sequence of an activity for the parent/caregiver; and
Generalized the strategy to other routines with the parent/caregiv
er.
5. What strategies/activities
did you and the
parent/caregiver
collaboratively agree to do
to support their child’s
l
earning and development
between visits
?
Outline the strategies/activities that the parent/caregiver has agreed to do until the next visit.
Indicate here if the parent/caregiver did not agree to work on a strategy/activity with the reason (if
given).
During each visit, the interventionist and the parent/caregiver can determine and collaborate
together on which learning activities:
Will be integrated into the child and family’s natural routines, based on family’s comfort
leve
l.
Will be used to build upon the child and family’s strengths and competencies.
Can be used by the family without the presence of the interventionist.
Include the following information, if applicable:
If the child is authorized for an AT device, describe how the family will use the devi
ce as
part of the child’s daily routine.
Support the generalization of the child’s new skills and abilities. Describe the
framework of the strategies and whether they may be used in other natural routines when
the child and family feel they have been successful.
Include recommendations made by other interventionists working with the
NYC Early Intervention Session Note Instructions 9/2015
parent/caregiver and child whenever possible.
Parent/caregiver signature
and relationship to the child:
At the end of the session, the parent/caregiver who participated in the session signs the session
note and indicates his/her relationship to the child. The date written on the note is the date that the
parent signs the completed note. A parent must never be asked to sign an incomplete, blank,
or undated note.
*This does not apply for facility-based or group developmental serv
ices.
Interventionist signature,
credentials, date and
license/certification number:
The interventionist signs the session note and adds his/her credentials. If certified, write
“certified” and do not indicate number. The date that the session note was created, and signed by
the parent, is then entered.
For sessions with student interns, CFYs, OTAs, and PTAs, this field may also include the
signature and license/certification number of a supervisor, as applicable. A date should also be
indicated.
Procedural Notes:
A Family Activity Sheet is available to help support the parent/caregiver in the learning activities until the next session (it follows
the session note in this chapter of the NYC Policy and Procedure Manual, and is also available on the www.nyc.gov website).
The Family Activity Sheet is a voluntary tool that can be used to document the strategies that the family plans to use during
targeted daily routines. The type of tool that the parent/caregiver decides to use is individual to the family. They may decide to
use either the Family Activity Sheet, or a communication notebook, or a calendar or even a combination of these tools. They may
also use different tools at different times, or decide not to use any tool.
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- NYC EIP Session Note 8 2014 - V 1 (City of New York)

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Completed 24 October 2021

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