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charting progress notes


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A Student posted this question in my Volunteer Workshop and thought I would post it in the message board so that others may read and learn from it.

 

-Miguel

 

I'm puzzled about this... I understand the MDS has a 7 day look back for assessment time and the ARD date has 7 days to completion for careplan date. Here is where I'm confused... My progress note needs to match the same 90 day date as the careplan ?? Do you write the progress note at careplan? Thanks for your imput.

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A Student posted this question in my Volunteer Workshop and thought I would post it in the message board so that others may read and learn from it.

 

-Miguel

 

I'm puzzled about this... I understand the MDS has a 7 day look back for assessment time and the ARD date has 7 days to completion for careplan date. Here is where I'm confused... My progress note needs to match the same 90 day date as the careplan ?? Do you write the progress note at careplan? Thanks for your imput.

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Well obviously no one had anything to add so I thought I would give it a shot...

 

Progress notes should be written around the same time that you are doing the quarterly updates on careplans..... It is human nature to of course be a few days off either before or after..

 

I would suggest you use some form of Tick Sheet or like my Medical Records Director does is provides us a report every month on what progress notes are due for the month and complete them according to your Assessment and MDS date.

 

The progress note paints a picture of the resident and with the New Interpretive Guidelines should be a tool to evaluate the outcomes of careplans.. (measurable outcomes based on programs provided by you the director) If careplanned interventions and goals are not being met than they need to be changed and the progress note can be the place to make these chages. progress notes also can be reflect on any accomplishments that the resident has completed in the last quarter or any declines they may have.

 

Hope this helps..

 

-Miguel

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