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when writing progress notes concentrate on what you actually want other stakeholders to know. Refer only to resident, client etc no name.you are already in the casenotes of the resident.Remember to write short note on what the client did, taking into account description of action. As a lifestyle therapist you must only report what occurred not what you think happened.Read other professional progress noting this is good idea to get used to terminology used. Example. Resident attending knitting today socially interacting with other clients.Enjoyed teaching others her knitting skills and commented how she looks forward to coming next time. Hope his helps, progress noting is not easy and you have to think what you are writing as this is a legal document if you not sure seek assistance.

Thank you very much Wendy , that is a very good explanation which helps me to know how to write a progress note for the Client .

I am so please to be a member of Golden carers .

I would be very careful when writing in progress notes stating ' Resident ENJOYED the activity ' If I observed that they looked like they enjoyed the activity, I will write 'Resident SEEMED to enjoy the activity'. The only time I will write the resident enjoyed the activity is only if the resident stated that to me verbally....therefore this is fact. Never assume residents enjoy an activity by observation only - I have had accreditors ask 'How do I know that resident enjoyed the activity ?

Yes, Wendy is right. When writing progress notes you need to keep it factual and to the point. Also, proof read what you have written and check spelling. Spelling mistakes in any work is not good enough.

Cheers

Hi there, Im very interested to learn what terminology use in Progress note. I wish someone will share . Im doing nail care and hand massage

These articles may be helpful:

How To Write Progress Notes

https://www.goldencarers.com/how-to-write-progress-notes/3299/

Professional terms to use in Resident Reporting:

https://www.goldencarers.com/professional-terms/3210/

Thank you, Talita

You can also purchase books that help with the process of Care Planning. Check out resources such as Nasco, Seabay and S & S catalogs.