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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