Newsletter Resource · Documentation

The DBHDS-Compliant Daily Note

What surveyors expect to see, in 5 lines or less. With sample wording for each service type.

Every daily note should answer four questions: What did we do? How did the individual respond? What progress did we observe against ISP outcomes? Were there any concerns? CareHub's Smart Draft auto-fills the first three from the active PCP. Use this card to coach staff on the fourth - and on what to never write.

The 4-Part Frame

1

Activity

What was offered + what the individual chose. Specific, observable.

"At 10:15 a.m. I supported John in reviewing his grocery list and walking to Kroger to shop for the week's meals."

2

Response

How the individual engaged. Behavioral and verbal observations only - no diagnoses or assumptions.

"John selected 6 of 8 items independently and asked for support locating frozen foods. He smiled when greeting the cashier."

3

ISP-Outcome Progress

Tie back to a measurable PCP outcome.

"Progress toward Outcome 2 (community shopping with minimal prompts): 75% independent selection vs. 50% baseline."

4

Concerns / Follow-up

Anything that needs supervisor attention, even if minor. Empty is fine - but never omit.

"None this shift. John reported mild left knee discomfort on the walk back; will monitor and report if it persists."

Things to Never Write

Diagnostic language

"Anxious", "depressed", "manipulative", "non-compliant" - these are clinical conclusions, not observations. Replace with what you actually saw or heard.

Future tense without action

"Will work on community skills tomorrow" is not documentation - it's a promise. Document what you DID, not what someone else might do later.

Vague time references

"Earlier in the shift" is unauditable. Use clock times.

Group notes for everyone

Each individual gets their own note. "All residents had a good day" doesn't fly with surveyors.

Smart Draft shortcut: Open Daily Notes → New Note. Smart Draft pre-fills sections 1–3 from each individual's active PCP outcomes and supports. Staff add the response specifics + concerns and sign. Most DSPs report 5–10 minutes saved per note.