Writing activity progress notes could be time intensive but it's an essential facet of documentation. F-tag 248 clearly states that there has to be a method that each resident's program of activities is supervised. You will find many different ways to accomplish progress notes. Here are two good examples of the quarterly progress note.
Mrs. X
Quarterly Review:
1/20/02
Since her admission on 10/9/01, Mrs. X has went after an energetic leisure lifestyle. She's alert and oriented to any or all area and makes her needs known. She's interpersonal with both staff and peers and initiates conversations. Her family people are extremely encouraging and visit weekly, supplying additional reading through materials and Mrs. X's favorite meals. Mrs. X is definitely an active participant in daily leisure activities both off and on the system including exercise programs, modified physical games (bowling, basketball, ball games), word games, bingo, trivia, discussion, Beauty groups, music programs, cooking and crafts. Mrs. X also became a member of the Resident Council and it has attended 1x this quarter. She's been asked to go to the Youthful Adult Group, however has rejected. She likes visiting the green house for gardening therapy periods and also the off unit special occasions. Although a practicing Roman Catholic, Mrs. X states she finds much strength in attending chapel services of faiths. Mrs. X likes a number of independent activities including: speaking on the telephone in her own room, hearing music on her behalf Personal stereo (country and 50-eighties music), reading through large print books, crossword puzzles and watching movies in her own room. Entertainment Staff provides movies, crossword puzzles and enormous print reading through materials. Mrs. X has instances of tearfulness and frequently dwells on her behalf illness. Entertainment staff encourages her to wish, pay attention to favorite music, or find solace within the green house if Mrs. X doesn't express curiosity about joining the audience activity. Entertainment staff continues to ask Mrs. X to daily leisure activities and supply supplies for independent hobbies. Additionally, Mrs. X is going to be urged to go to the Youthful Adult Group to spend some time with citizens of her age bracket for further support and companionship. See care plan # 3 addressing mood and behavior, for specific interventions. Mary Sunshine, ADC Activity Director
Mrs. P
Quarterly Review:
9/8/02
Mrs. P remains alert with confusion and forgetfulness. She's oriented to self and her speech is restricted. She responds to simple direct questions by nodding her mind or mumbling. Mrs. P is OOB daily inside a reclining chair and stays much during the day within the dayroom where she's involved in leisure activities including Snoezelen, Five Alive, Physical and Movement, Music Therapy and modified reminiscing groups. R/t to poor cognitive status, Mrs. P requires extensive assistance (i.e. give hands, physical/verbal cueing) to sign up in leisure programs. R/t contractures of both of your arms she will get U/E and L/E Promenade throughout modified physical games and use programs to keep physical functioning. Throughout physical programs, a number of Leisure techniques are employed to elicit reactions to stimuli including: Aromatherapy for olfactory stimulation hands massages, textured objects and props (yarn) for tactile stimulation pictures of great interest (felines) fiber optic lights and bubble towers for visual stimulation frozen treats, pudding, flavored lip lotions etc. for gustatory stimulation and music (Italian and singalong) in addition to character sounds, for auditory stimulation. Mrs. P responds to physical stimulation by monitoring objects, vocalizing, smiling, laughing, whistling, and tapping ft and hands. She especially likes Italian music and also the song "O Solo Mio". She also takes part being debated and memory groups when requested closed-ended questions. Entertainment staff provides face to face physical programs PRN. Family visits are irregular. Entertainment staff continues to supply physical stimulation to boost reactions to exterior stimuli and keep quality of existence. See care plan number two addressing contractures, for specific interventions. Mary Sunshine, AAC Activity Assistant
If you are thinking about an simpler method of finishing progress notes you might want to think about the following product from Re-Creative Assets Corporation. Entertainment Progress Note: That one-page form can help you write Progress Notes, easily and completely. Simply write phrases or short sentences within the spaces provided. It offers areas for example: Face to face Interventions, Group Activities, Reactions to Activities, Degree of Participation, etc. Additionally you get the "Aspects of a Progress Note" tool that designates various good examples with the Progress Note Form for every category listed. To buy the product go to the re-Creative Assets Corporation. website.
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