careplans & progress notes

[Jewels 0]

Hi, I'm jewels

I'm new to postings, I have a question about documenting in careplan & progress notes. Do you have to state how many times a week a resident will attend activities or when AD does 1:1s, as long as it's documented in activity log book or 1:1 log book ?

Edited April 28, 2007 by Jewels

[Cale 0]

Hey Jewel,

 

Each resident should have a record of all the activities that the resident participate from 1:1, grp, or indenpendent. In careplan you have the Problem/Needs, Goals, Aproaches. The careplan goals is not measurable but a at least your trying to accomplish that goal you set for resident. The resident attendance record should be very helpful in your quarterly notes that you can look what the resident is doing etc etc...

[bigchris 1]

It is a good idea to be as specific to the resident about thier preferences of activities. WHich activities are more effective and any breakthroughs/declines that the resident has. You should document as much as possible...for example. I progress note for at least 5 residents each day based on what we did that day. I do this because each morning we metion the residents who have issues and I try to see them specifically.

 

According to the new regs, you should have other documentation from other departments based on the activities that they are doing. With this, I have attendance logs for other departments and I debrief with them after the activity.

 

Hope this helps,

 

 

Chris

[RobinLynn 0]

this is what a typical progress note would look like for my resident: Res. cont. to reside in room 202, res. is A+Ox3. Res. in w/c-able to propel self. Res. cont. to attend group act. Res. attends: and I document all activities they go to, I document if they use adaptive equiptment. How they participate. Do they need encouraging/cueing. Does music set them off, do they start dancing. I simply document responses. In all my progress notes, I will document physical, mental, social and spiritual for each resident. I will document when family comes ie: family visits regularly-very supportive of res. needs. That shows more socialization even when not in activities. Any questions, feel free to email rhermida424@aol.com, my name is Robin

[Mel 0]

The new guidelines specifically state, and I quote

 

Activitiy goals related to the comprehensive care plan should be based on measurable objectives and focused on desired outcomes (e.g. engagement in an activity that matches the resident's ability, maintaining attention for a specific period of time, expressing satisfaction with the activity either verbally or non-verbally), not merely on attendance at a certain number of activities per week/month.

 

So do not put in the # of times per month/week/day that you are going to do something with each resident in a care plan. Plus if you put in 3x/week and only do two you could get an Ftag.

 

You should have a daily attendance log where you chart who was in each activity and their level of participation. On that same log you can log in room visits and what they did/their level of participation.

[OceanGuy23 2]

Hi all

Can anyone tell me where I can get a really good resource book for doing care plans. Just thought I would get some opinions. Thanks.

OceanGuy23

[Britt 0]

Hello. Can anyone give an example of a Sig Change progress note for MDS care planning