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Progress Notes by Kathy Hughes, ADC ActivityDirector.org Recently there has been conversation on social media sites concerning the need for activities to complete progress notes on a quarterly basis. This can also mean a quarterly and annual reassessment of the resident. Let us look at what a “Standard of Practice” is for Activities: Standards of Practice are a “how to” of a discipline. They can include policy statements, standard operating procedures, activity practice protocols and procedures for specific activities. Policy statements clarify the scope and authority of activities stating who, what and when an activity takes place. It also covers the scope of practice for the activities department. A scope of practice may be that activities cannot diagnose a specific disease or disability. The Standards of Practice also include the documentation requirements as set forth by the federal government and regulations of each state. These standards may not appear in the Activities section of the regulations but may appear in the Clinical records portion of the regulations. A policy is written by the Activities Director for the Activities Department. Once a policy is instituted the Activities Department must abide by what is written. A procedure is how the policy will be performed and how the Activities Department will do the activity. When being inspected, a surveyor might look first at the federal regulations then the state regulations and if there is a question then the facility policy and procedure. In the past some facilities received a deficiency when they did not follow their written policy and procedures. We have looked at the federal regulations for the US and found information that there were some references to progress notes for all disciplines, but not activities specifically. Although there are no regulations for having to do quarterly progress notes for activities, it is a Standard of Practice for the Activities profession. It is also a policy and procedure in most nursing homes. Surveyors are directed to look at “Physician’s, nurse’s, social worker's and other staff members progress notes, as applicable” in many areas of the CMS (Center for Medicare and Medicaid Services) regulations. “Other staff members progress notes” would be where the Activities Department falls. State by State Regulations Some state regulations specifically state that quarterly progress notes are required by the Activities Department. There are other states that only follow the CMS Regulations. It would be up to the Activities professional to find their specific state regulations for the need for a progress note. Here is a link to the “Clinical Records Regulations” for each state: http://www.hpm.umn.edu/nhregsplus/NH%20Regs%20by%20Topic/NH%20Regs%20Topic%20Pdfs/Clinical%20Records/category-administration-clinical%20records-final.pdf You can access your state regulations for activities by using this link: http://www.hpm.umn.edu/nhregsplus/NH%20Regs%20by%20Topic/Topic%20Quality%20of%20Life.html#statecompare You can also go directly to your state Department of Health and do a search for your specific regulations. In Summary... The Activities Department should do quarterly progress notes as a Standard of Practice. We have valuable information to share with the staff, the physician and the other teams. The residents have unique needs and interests that need to be documented and their progress in activities could impact their medical conditions and their progress in the facility. In our never ending quest to be accepted as a valuable member of the facility team writing progress notes, actively contributing to the care plan and having a detailed Initial Activities Assessment lets others recognize the Activity professionals as a modality to improve the residents quality of life. Have a question for Kathy? Email questions and comments to firstname.lastname@example.org. Thank You. ENROLL Now Activity Directors Network was founded in 1996 on the idea that we could help create elderly care that dramatically improved the lives of those we all serve. Activity Directors are the key to creating environments that we ourselves would be excited to live in. We envision facilities that feel like homes, not institutions. Facilities that celebrate our resident’s individuality and allows them to live with dignity, purpose and joy. We believe providing the best education available, with the most talented teachers we can find, is the way to make an impact. Each and every single one of you are the revolution that is changing everything. Thanks for being a part of The Network. Copyright © 2019 Activity Directors Network, LLC All rights reserved. Our mailing address is: 2010 US HWY 190 W Ste 120 Livingston, Texas 77351
Hi. Along time ago when I started in Activities, 80's Writing a Care Plan was difficult, I read and I watched and I learned.. but it took a while, had a wonderful mentor , Pam Sanders, very good memories. We have had several people ask about CarePlanning so I thought I would share. Here is something I wrote to help others struggling with the process, Its in my simple language, and I hope it helps any of you starting out. Its written in a basic way, to help you understand the concept. When you write your careplans you should write them in a Person Centered form, address everyone by their name, define the activity you are using to help with the concern, define the activities on your 1 on 1 cart, relay the residents feelings, their reactions, their participation, in essence tell a little story about each of your residents and how you care for them as individuals. Everybody loves to be cared for. to Write a Careplan We gather information on a resident by doing an assessment / resident interview. Using the information from the assessment allows us to design a comprehensive plan of care. The ICP (Interdisciplinary Care Plan) Team would then meet to form a Care Plan for a resident. The Care Plan must address 3 areas of concern in order to be a complete plan The concern: What and Why The goal: When and How Often The approach: How and by Whom Create your Care Plan First - define the problems / needs / concerns for your resident. What is the concern and Why is it a concern. Resident (Ms Jones) does not attend activities due to Hard of Hearing (remember Person Centered) Resident refuses to follow diabetic diet orders Resident unable to feed self due to Alzheimers Question? Is the concern d/t (due to) a secondary cause, an underlying reason or is it a concern of the staff, but not for the resident? i.e. Resident will not participate when attending an activity. � This is not a problem with the resident, maybe he/she is a people watcher.. he/she just likes watching.. But the staff has a concern that he/she does not join in� still it is not a concern with the resident. i.e. Resident prefers to eat breakfast at 10am. This is not a concern for the resident, it is a concern for dietary, unless they wont serve he/she a later breakfast, then it�s a problem, it is the residents right to have breakfast when he/she wants, and dietary should comply. Second- define realistic goals. Define the schedule and time limit for the goal(s) to be met. How Often will you and your resident work to acheive the goals and When will the goal be accomplished A goal should simply address your concern, it should not be unobtainable, just a resolution to the concern. It is helpful to ask, What is the problem? The answer will lead to a realistic goal. The goal should be a phrase or statement in which the residents progress can be evaluated and their concern resolved. i.e.Concern: Resident is depressed bad Goal: Resident will be less depressed. (progress cannot be measured) good Goal: Resident will choose 2-3 activities to attend each week. Third- define your Approaches to obtain your goal(s) How - Create procedures / strategies to acheive the goal(s). By Whom will the procedures be conducted The Approach is your plan or strategy to meet your goal(s) and resolve the concern. The approaches should be the steps to be taken, specific services to be offered and who is responsible for implementing the approach. Some approaches may have only one department assigned and others may have all departments assigned. i.e. Concern: Resident is a diabetic and non-compliant with her diet d/t (due to) refusal to accept DX (diagnosis) of being a diabetic. Goal: Resident will be compliant with diet and aware of the risks of refusal x 90d (times 90 days) Approaches: Offer resident alternate choices in food - A,D,N (Activities, Dietary, Nursing) Remind resident of risk when refusing to comply with diet orders - A,D,N,S (Activities, Dietary, Nursing, Social Worker) If resident refuses to comply with diet, inform nursing or social worker - A,D,N,S Praise resident when he/she follows diet restrictions - A,N,D,S Ask family to stop bringing candy and other foods that are non-compliant with residents diet - A,D,N,S Have dietary speak with resident and family members about the disease and offer alternate foods choices - D A-Activities, N-Nursing, D-Dietary, S-Social Worker Approaches should not be specific tasks, make your tasks universal and non-specific to allow variety in your proceedures. Note the specifics in your progress notes. and dont careplan yourself into a corner, if you say Ms Jones will attend or participate in an activity 2 times a week, than you had better keep good participation notes showing that 2 times a week is what Ms Jones did ., sometimes its better to be less detailed in your plan, and more specific in your progress notes. Have a Happy Forth... Pennie thanks for being a part of Our Network
Activity Director Documentation Course. Activity Documentation Complete - Assessments thru Progress Notes 10 CE Hours NCCAP Approved Instructor: Kathy Hughes If you are having trouble with your paperwork .. than this course may be exactly what you need. This course will teach you exactly what documentation is needed to satisfy your State Survey, by the book. We will compare exactly what is written in the regulations to the paperwork and forms we use everyday. Is your "Assessment Form" survey proof? What are the five questions the State Survey team is going to ask about your Assessments, Progress Notes and Careplans as soon as they enter your building? .......... We will help you answer those questions before they get there.. Paperwork, Paperwork and more Paperwork.. The key to cutting down on paperwork is knowing exactly what you need and what you don't need. visit ActivityDirector.org for more details