Activity progress notes

[iwendland 0]

Does anyone have guidelines on how to write a progress note. I am teaching my assistant on how to write care plans and progress notes but I would like some guidelines for her whenever I am not here. If anyone can help, I would really appreciate it.

 

Thank you,

Irene

[aRBeRec 0]

Does anyone have guidelines on how to write a progress note. I am teaching my assistant on how to write care plans and progress notes but I would like some guidelines for her whenever I am not here. If anyone can help, I would really appreciate it.

 

Thank you,

Irene

 

 

This is something that I was given a while back on notes:

 

Documentation: Progress/Quarterly Note Guidelines

 

1. Change or no change; Trigger or does not trigger

a. Why or why not?

b. How? Describe

2. Able or unable to determine own routine

a. Initiates independent activity pursuits?

3. Level of participation and attendance

a. Group activities

b. Is the resident engaged?

c. Resident’s response, if not able to verbalize

d. Independent pursuits (describe)

4. Sense of residents daily routine

5. What am I doing? Care plan?

6. Proceed or do not proceed with care plan

 

 

Key Phrases or Words:

Avoid standards of care, i.e. invite, encourage

Consistent/inconsistent

“During activities resident…”

“Enjoys XYZ programs as evidenced by…”

“Proceed with activity approaches under comprehensive care plan”

“AT will…” be specific, i.e. one to one 3 times a week, discuss past interests, sing songs, etc.

 

Hope that was helpful

[Pennie 26]

A new definition that can legally be used on a residents progess notes or care plans: (per the MDS 3.0 Manual)

 

Inattention:

 

Reduced ability to maintain attention to external stimuli & to appropriately shift attention to new external stimuli. Resident seems unaware or out of touch with environment (eg., dazed, fixated, or darting attention).

 

 

Just a FYI for everyone

[iwendland 0]

Thank you Pennie, that is very helpful.

 

Irene

 

This is something that I was given a while back on notes:

 

Documentation: Progress/Quarterly Note Guidelines

 

1. Change or no change; Trigger or does not trigger

a. Why or why not?

b. How? Describe

2. Able or unable to determine own routine

a. Initiates independent activity pursuits?

3. Level of participation and attendance

a. Group activities

b. Is the resident engaged?

c. Resident’s response, if not able to verbalize

d. Independent pursuits (describe)

4. Sense of residents daily routine

5. What am I doing? Care plan?

6. Proceed or do not proceed with care plan

 

 

Key Phrases or Words:

Avoid standards of care, i.e. invite, encourage

Consistent/inconsistent

“During activities resident…”

“Enjoys XYZ programs as evidenced by…”

“Proceed with activity approaches under comprehensive care plan”

“AT will…” be specific, i.e. one to one 3 times a week, discuss past interests, sing songs, etc.

 

Hope that was helpful

[ccrisanto 0]

Hello, my name is Cathy and I am taking the MEPAP1 class this time around and here is an idea:

I have been taught to write something like this:

 

Resident enjoys music programs, family and friend visits and outings. Resident has been coming to current events and has particapated in the quetions and answer period. Staff will encourage resident to come to other activities during the week.

 

I hope this helps. I try to be concise and to the point so that there is no question when the note is read as to what the resident likes or dislikes.

Cathy

 

Does anyone have guidelines on how to write a progress note. I am teaching my assistant on how to write care plans and progress notes but I would like some guidelines for her whenever I am not here. If anyone can help, I would really appreciate it.

 

Thank you,

Irene