Quarterly Summary

[karenleung 0]

Hi all. How do you do your quarterly summary? Do you use forms with check boxes or do you write up the summary or progress note? The reason why I ask is because most of our residents' status/condition are quite steady with no significant change. When activity staff write quarterly summaries, they would put down what programs the residents participated in the last 3 months and if they were active or passive. Is this how you write quarterly summary too? If you use forms, could you share? Thank you.

[Kerrie 0]

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.

[karenleung 0]

Hi Kerrie, thank you very much for your feedback. It's very useful and I like the SOAP format. Like I said in my posting, quarterly summaries for residents who are in steady condition look pretty the same every quarter. I am thinking of developing a form where staff only need to check the boxes and only actually write a summary when there is a significant change in condition. Suggestions welcomed. Karen

[Pennie 26]

Hey Karen,

I use the progress note form for my quarterly reviews. I wwrite the date , Quartely Review, which quartely & the proceed w/ the note/summary.

The first line is what was/is the res. goal from the annual/new asses. If this has been met or not. The a summary of what act/ res has attended, brief desc. of res. any type of changes in res (be it act or any other dept.) Then end it with a note on wheather the goal will be con't, d/c'd. revised (if revised explantion as to why). The sigh off on it. Even thought most res. don't change to much you need to document it does not need to be long just a brief note will do. I would rather write a short note than to check a box. The note method seems to be more personlaized to me. Hope this helps.

[karenleung 0]

Hi Pennie, thanks for the feedback. I agree that the note method is more personal and it does not have to be lengthy. Karen

[gina 2]

Hi Karen,Karrie and Pennie,

I too have always opted for a short note for quarterly notes.

I have found that it is more personal and the state likes that too,also I think that although it might take a little more time you will remember that resident more easily than if you just checked boxes on a form(and when you have 100-200 res.its easy to forget each residents charting-lol ).

Whatever works for each Director is all that matters. ;-) gina