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Raw note

worked with james today, did community access, he had a meltdown at the shops because he was being difficult. calmed down after a while. gave him his meds at 2pm.

Length: 162 chars · 0 plan goals linked · 1 banned word (“meltdown”) · no incident screen

NDIScribe rewrite

Note Quality Score: 100/100

Date: 2026-05-26 | Worker: SW initials | Participant: J.M. | Service: Community Access | Location: Westfield Penrith | Time: 13:30–15:45

Supported James to access the local shopping centre as part of his Goal 2 (community participation).

Behaviour observation: At approximately 14:10, James raised his voice and stated "I don't want to be here, take me home" near the food court. James did not respond to two verbal prompts to take a 5-minute break in the quiet area. Behaviour de-escalated within ~8 minutes after we relocated outside the centre. No physical contact required, no incident report triggered.

Choice offered + made: James was offered three options for the next destination (home, café, park). James chose home.

Medication: Administered scheduled 14:00 dose of [medication name] as per medication order #234, signed and witnessed by SW initials. No refusal.

Risks identified: Sensory overstimulation in busy retail environments. Mitigation: short outings, pre-agreed exit point, headphones available.

Goal-linked: Goal 2 (community participation) — progress on track. James independently selected items at checkout for the first time.

Handover: Daughter S advised at pickup that James was unsettled at the centre; recommend shorter outing duration next attempt.

No incidents to report.

Rubric breakdown (15 criteria)

✓Participant identified+5
✓Worker identified+3
✓Date + start/end times+5
✓Service type / line item named+4
✓Location of support+2
✓Observable behaviour, not interpretation+6
✓Banned subjective words avoided+3
✓Verbatim participant quote+3
✓Choice offered + made+3
✓Medication: name, dose, time, route, refusals+5
✓Risks identified + mitigations+8
✓Goal-linkage with progress direction+8
✓Incident screen completed+6
✓Handover plan present+3
✓Within 24h contemporaneity+3

Disclaimer: The Note Quality Score is guidance derived from rules-based validators and AI rubric scoring. It is not a regulator compliance attestation or legal advice.

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