Hi Karen, for the past 4 years we have been doing our quarterlies (and initial/rap assessments) on the computer. We input our MDS info then click on the rap narrative section and type away. Even though it's in paragraph form with out any structure to guide me I still use the format I used when I wrote my assessments by hand -- a basic "SOAP" format. My old form said "Activity Review" at the top then I would check whether it was a quarterly, annual or change of condition assessment. There are sections following "SOAP":
S: subjective or what the resident's perspective is. Example: "I feel so busy! You activity girls are the most fun, beautiful, creative people on the planet!" or "I would like more to do on Sunday afternoons." If they cannot give their perspective, write what their family member says or physical clues that the goal is being met ie eye contact, smile, etc. ie "Resident is unable to give a verbal response but smiles and gives eye contact when activity staff enter her room."
Then I write what this resident's strengths are, especially ones that help them meet activity goals.
O: Objective. What we see the resident doing. How they spend their time ie solo, groups or 1:1 activity, family involvement. I have a separate section for groups and 1:1 or independent activities. This is where I write how we assist them to participate, what they need from us.
A: Assessment. Assess what their needs are. Does anything need changing from our perspective or the resident's? Do they want anything more or different to do? Have they had any changes in leisure patterns or interests over the quarter?
P: Plan. I write about areas triggered or that were not mentioned above.
I might have left out some information, but I hope this helps you to develop a form that works for you. I made my own form from looking at several and taking the parts that made sense to me. As I grow and change professionally so do my forms.
Have a great day, Kerrie.