Doing Progress Notes

[deelconnie 2]

I am learning how to do progress notes on new admits. What should that note include.

[fawnwhite 0]

When I'm doing a progress note, I include the following:

Example:  Initial Note: For ARD of 5/16/15 (whatever your ARD date is... Neighbor is a 59 year old male, alert, verbal, and oriented x 3, (or describe - ) with cognitive and communication impairment or communicates via head nods, mouthing or writing words, or grimace, (If they are - just give a description of what you see or know about the person from interview)  Neighbor propels himself independently throughout the facility, enjoys eating his meals in the dining room, is social, and pleasant.  His activity interests include... (put information acquired through his assessment) Enter his diagnosis, limitations and strengths, and your plan for him, i.e. Activity staff will invite to group programs of choice, provide social RV's, and leisure materials upon request, observe unstructured time, and assist with transport as appropriate, and I usually end with see POC and goal for further information - and make sure what you write in your progress notes matches up with your care plans!

 

Hope this helps!

Fawn from PA

[activities25 0]

When I am writing an admission progress note, I make sure that I write that she was oriented to the activity calendar located in their room, there activity preferences, interests that I collected from the activity assessment & social history interviews, whether or not they like to take a nap during the days and if they "mostly prefer" individual, group or both activities.  Hope this helps!

[Britt 0]

Can someone help me with examples on writing a Sig Change progress note. Fairly new director here. Thank you guys!