12 Tips for Writing Progress Notes

ideas for colouring /painting theme /art/ education / documentary. I choose a specific animal/or bird or a different subject choice. I get the residents engaged in colouring in or painting/read out the facts aloud while interacting and assisting when needed and after we watch a documentary on the subject of choice/or animals /bird .Lifestyle /dementia.

Hello all, can you provide some examples of how you document salon services? Thank you!

Hi again

Most facilities have an apartment or two for lower income people

Usually they give them to people who have run out of money but every place is different

Also some residents may get hurt and need rehab which they may or not may not provide

Thanks for the medicare distinction, Susan. And are medicare funded more of the low income communities? Where my parents live is a private company that owns several AL communities. I've never seen medicare mentioned but perhaps it would be listed in the contract? Yeah it's good practice! They don't know what their staff are doing as the director said unless he follows staff around. Mind boggling.

Hi Susan

It depends if the facility gets Medicare funding or some other funding from the state as to whether progress notes are required

Is just good practice to write notes periodically so that others can look at the chart and see what is going on

It is important to write the notes when there is a change

Hi, When are progress notes required by Assisted Living? I was told today by the state of Virginia Dept of Social Services that charting, recording of daily care of residents at Assisted Livings is not required, not in the state regulations. So how do progress notes fit into this? How is there any beginning of accountability without required notes? Yes staff can lie about it and checkoff even if they didn't do what is in the Care Plan, but not requiring any notes doesn't make sense to me.

Can anyone please tell me how to write a progress notes.?

Hi everyone

Is any one can help me to write a month progress note . For a resident who who does verbalise,very frail who previously lost the ability to use her left thumb to communicate yes or no . Since admission she declined to attend social activity.

using personal Experience) write brief details on at least that you would include in a report

1 state of the client- physical, emotional, culture and spiritual

Thanks everyone

any one can help me to do the reporting/recording home visit

using personal Experience(family or neighbor) write brief details on at least that you would include in a report the following a home visitation

1 state of the client- physical, emotional, culture and spiritual

2.codition of the premise maintenance issues

3. food supplies, utilities_overdue bills

Can any one give me a example how to make document of daily care

Can you please give me some suggestion. I am new have 14 clients were unaware that quarterly review needs to be completed. What do you recommend to rectify my problem? This does not include past clients.

This site is really helpful and useful. I am so thankful and glad that I joined this site. People here were great!!! Love you all

Hello Amtul, I Hope this helps also.

Care plan: Leisure and Lifestyle

Name: xxxx

D.O.B.

Room No.25

xxx ambulates well unaided and always enjoys a chat. xxx does not speak another language except English and does not require an interpreter. Xxx t has regular visits from staff, family and volunteers and socialises with others in the common areas, such as in her unit, dining room, facility, gardens, and walkways on occasion. xxx is not at risk of social isolation. xxx has a quiet and gentle nature and is most willing to not only participate but to contribute to attended activities in a practical way. xxx is not a social person, but is compliant and eager to please, thrives on 1:1 interaction, always willing to engage with staff, other residents and visitor's to the home xxx privacy is respected at all times. Staff and visitor's knock before entering her room.

Independence/Choice and decision making

xxx enjoys being actively involved, independently choosing to participate in activities of her choice. Staff support xxx choices by allowing xxx to choose which activities she would like to do. xxx participates according to the activities program, requiring a reminder and an escort to the Activity room or to the courtyard some time before the activity begins from L&L Staff and volunteers to attend.. xxx independently chooses to have quiet time or a rest in her room on occasion, or to go for a walk around the facility and into the gardens on the walking path. Xxx is definite in her likes and dislikes and is able to articulate her needs. Xxx attends Resident & Relatives meetings. xxx enjoy 1:1 time and is given the opportunity to voice any concerns she may have during 1:1 chats in her room. xxx receive social and emotional support in xxx room, or in the Activity area as documented in activities log, and folder during 1:1 visits from L&L staff and volunteers.

Group Participation:

xxx attends a range of activities of her choosing, and participates effectively, remaining engaged throughout the duration of the activity. Her involvement in the L& L program activities suggests a balanced lifestyle, and all risks are assessed and considered safe. xxx reads her monthly program on the notice boards and the weekly activity plan in her room in her room, which the DT provides. xxx is capable of self-initiating to some activities on occasion but prefers a reminder and an explanation of the activity. xxx enjoy physical activity, in varied forms but is particular which activities she attends, eg . Disliking bowling but prefers skittles. No member of the xxx family or xxx have requested or suggested any further activities to cater for xxx needs or interests. an xxx family are happy for xxx to spend time contentedly amusing herself in her room as this is an xxx pattern of behaviour for many years. Dt did suggest that xxx1:1 time with volunteers and staff be increased to prevent possible social isolation.

Spiritual Identity:

• xxx attends religious, spiritual and pastoral care routines and continues to celebrate Christmas, Easter, and birthdays according to the program plan.

• and enjoyed the busy festivities of Christmas and the leadup to Easter

Complaints and Compliments:

During xxx evaluation meeting, xxx was reminded of the complaints procedure and is aware of her rights. xxx has not asked for an advocate .xxx has no complaints. xxx is pleased with staff in general and said xxx is happy.

Meaningful Contribution:

xxx has a role sorting the magazines in the activity room. Risks are assessed before xxx takes on any tasks.

NEXT REVIEW: September, 2018

Olwyn N (DT)

17.06.2016

Here is one example of a quarterly review.

Over the past months, has been involved in 162 activities, 60 Individual visits from family, friends, staff or volunteers.

Before xxxx came to live at the home she lived a quite, almost solitary existence. Her main interests were nature, and various pets on a rural setting.

xxxx enjoys reading magazines, listening to music and small group activities and sitting in common areas. However, is reluctant to attend large group activities.

DT has invited xxxx ladies group afternoon teas. xxxx has attended on most occasions and has interacted socially with the other ladies.

xxxx has not spoken to DT staff in relation to emotional support but often becomes anxious and needs comfort and reassurance.In particular, she worries about her animals, and whether she has left a tap running in her bathroom.

xxx or her family has not asked for an advocate.

xxx still enjoys attending many activities and her activity reports reflect a balanced lifestyle.

xxx has regular visits from her family.

Xxx is always welcoming of a conversation, but patience is needed to ensure xxx can respond and interact.

xxx also engage in social activity with other residents in the activity room, quiet areas, courtyard and facility and is not at risk of Social Isolation

Her privacy is respected at all times by visitors, and staff by always knocking before entering her room.

. DT provides a weekly individual activity plan and also places a copy on the corridor noticeboards.

Thank you for sharing the examples.

Would love to see some of your quarterly notes example if possible can you please post one or two examples. Thanks in advance

Thank you.

Need more information on residents who are on ACFI.

Daily progress notes pls.

Love these examples off progress notes , thanks

I am training a new staff person and will utilize some of the points here. Thank you. I love this site. In my quarterly progress notes I have a certain order. I write what the last quarter goal was, how it was met, especially enjoyed activity, observations about behaviors/enjoyment of activities, anything I have done for the resident, new goal, and how many programs attended or 1:1's for the three month look back period. This allows me to see the trends of participation.

Thank you.

Would love to see some examples of monthly evaluation of activities.