Step 1: Review the client's Treatment Plan

The Treatment Goals and Objectives are the basis to every BST note. It is best practice to get familiar with the client's Treatment Plan and understand what the client should be working on. It is best practice to familiarize yourself with the client's tx plan before a session in order to understand their rehabilitative goal(s).

Step 2: Take daily notes about the client

As a Foster Parent, we know that you are working with the client all day long, not just the 2 hour session. Document any behaviors, problems or comments about the client that can directly relate back to their Treatment Goals and Objectives. This is extremely beneficial in remembering what to write and can make BST notes more individualized.

Step 3: Understand the DAP Note Guidelines

Each portion of the DAP Note requires different information. Review the DAP Note guidelines and understand what is mandatory in each section.

  • DATA: A factual description of the session
  • ASSESSMENT: An evaluation by the reporter of the client's current status and progress towards meeting their rehabilitative goals.
  • PLAN: Statements about what will happen next session.

Step 4: Write the note

This is where you combine Step 1-3 into an actual BST note. Review your notes, make sure that the content in the note relates back to the client's Treatment Goals and Objectives, and place the appropriate information in the suitable DAP section. Do not document any unrelated or non-covered services.

Step 5: Review and Submit

As the provider, you are responsible for the content in every BST note you submit. Review the documentation for accuracy, selecting the correct goal, consistency, grammar, etc. Once completed electronically sign for QA submission.



Step 6: Review any Returned or Positive Feedback

Quality Assurance’s function is to help protect providers in their documentation. QA will communicate with the provider through returned notes for changes or provide positive feedback for suggestions for future notes within the note page. Make sure that you check your Note Page for these returned or positive feedback notes.

Step 7: Help!

If you ever require any additional assistance, don't hesitant to reach out. You can contact Quality Assurance by emailing us at Quality Assurance is always willing to assistant in any way!



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