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Writing action progression notes may be time consuming but it is an crucial aspect of documentation. F-tag 248 distinctly states that there ought to be a method in which each resident’s program of actions is monitored. There are galore ways to finish progress notes. Below are two examples of a quarterly progress note. Mrs. X 1/20/02 Since her admittance on 10/9/01, Mrs. X has pursued an active leisure lifestyle. She is alert and oriented to all realms and makes her needs known. She is sociable with both staff and peers and initiates conversations. Her family members are very supportive and visit weekly, supplying further and added reading materials and Mrs. X’s bestloved foods. Mrs. X is an active participant in every day recreational activenesses both on and off the unit including exercise programs, adapted physical games (bowling, basketball, ball games), word games, bingo, trivia, discussion, Beauty groups, music programs, cooking and crafts. Mrs. X likewise joined the Resident Council and has attended 1x this quarter. She has been invited to attend the Young Adult Group, nevertheless has declined. She enjoys going to the greenhouse for horticultural therapy sessions and the off unit particular events. Although a practicing Roman Catholic, Mrs. X states she finds much strength in attending chapel services of all faiths. Mrs. X enjoys a potpourri of independent activenesses including: talking on the phone in her room, listening to music on her Walkman (country and 50-80′s music), reading big print books, crossword puzzles and watching movies in her room. Recreation Staff provides movies, crossword puzzles and big print reading materials. Mrs. X has sequences of tearfulness and many times dwells on her illness. Recreation staff inspires her to pray, listen to bestloved music, or find consolation in the greenhouse if Mrs. X does not express interest in joining the group activity. Recreation staff will proceed to invite Mrs. X to every day recreational actions and provide furnishes for independent pursuits. In addition, Mrs. X will be encouraged to attend the Young Adult Group to spend time with residents of her age group for further and added aid and companionship. See care plan number 3 addressing mood and behavior, for specific interventions. Mary Sunshine, ADC Activity Director Mrs. P 9/8/02 Mrs. P remains alert with confusedness and forgetfulness. She is oriented to self and her speech is limited. She responds to simple direct questions by nodding her head or mumbling. Mrs. P is OOB daily in a recliner chair and spends much of the day in the dayroom where she is engaged in recreational activenesses including Snoezelen, Five Alive, Sensory and Movement, Music Therapy and adapted reminiscing groups. R/t to poor cognitive status, Mrs. P requires extensive assistance (i.e. hand over hand, physical/verbal cueing) to participate in leisure programs. R/t contractures of both arms she is provided with U/E and L/E PROM for the duration of adapted physical games and exercise programs to maintain physical functioning. During sensory programs, a potpourri of Recreational proficiencies are used to elicit responses to stimuli including: Aromatherapy for olfactory stimulation; hand massages, textured objects and props (yarn) for tactile stimulation; pictures of interest (cats) fiber optic lights and bubble towers for visual stimulation; ice cream, pudding, flavored lip balms etc. for gustatory stimulation; and music (Italian and singalong) as well as nature sounds, for auditory stimulation. Mrs. P responds to sensory stimulation by tracking objects, vocalizing, smiling, laughing, humming, and tapping feet and hands. She specially enjoys Italian music and the song “O Solo Mio”. She also participates in discussion and reminiscence groups when asked closed-ended questions. Recreation staff provides one to one sensory programs PRN. Family visits are irregular. Recreation staff will carry on to provide sensory stimulation to heighten responses to external stimuli and maintain quality of life. See care plan number 2 addressing contractures, for specific interventions. Mary Sunshine, AAC Activity Assistant If you’re fascinated in an posing no difficulty way of completing progress notes you may want to consider the following product from Re-Creative Resources Inc. Recreation Progress Note: This one-page form helps you write Progress Notes, effortlessly and thoroughly. Simply write phrases or short sentences in the spaces provided. It includes areas such as: One to One Interventions, Group Activities, Responses to Activities, Level of Participation, etc. You likewise receive the “Components of a Progress Note” tool that designates respective examples in conjunction with the Progress Note Form for each category listed. To order this product visit the re-Creative Resources Inc. website. |
