Progress Notes Basics
Documenting resident/client response to interventions is an integral part of the care planning process. This review of progress is known as a progress note. There are many regional variations as to how often, where and what should be documented. Most nursing homes document review of the care plan on a quarterly basis, in coordination with the MDS Quarterly. Most medical day care centers also adopt a quarterly time frame. Facility policy should define specific practice as to the timing, means and method of reviewing the care plan. The activity professional should rely on professional standards to guide appropriate content. It is also important to keep in mind – the purpose of the progress note, which is to document how the resident/client is responding to care and treatment.
The following areas may be included within any routine review of progress:
*Reassess resident/client for change in functioning compared to original assessment or last review. Has the resident/client improved or declined in functioning?
*Review resident/client participation within the activity program. Focusing on responses to activities and behavior within the programs is encouraged.
*Review response to any specific interventions, such as room visits, sensory programs or specialized activities for special needs. Again, we want to focus on how they are responding to the interventions, rather than simply stating interventions were offered.
*Note any barriers to implementation such as resident/client refusal or unavailability.
In addition to professional standards which guide our profession, the activity professional who works in nursing homes needs to reference the guidance for F-248 which indicates the care plan revision should include:
” Changes in the resident’s abilities, interests, or health;
” A determination that some aspects of the current care plan were unsuccessful (e.g., goals were not being met);
” The resident refuses, resists, or complains about some chosen activities;
” Changes in time of year have made some activities no longer possible (e.g., gardening outside in winter) and other activities have become available; and
” New activity offerings have been added to the facility’s available activity choices. For the resident who refused some or all activities, determine if the facility worked with the resident (or representative, as appropriate) to identify and address underlying reasons and offer alternatives.
Interdisciplinary Notes vs. Department Specific Notes vs. Episodic Notes
Regionally, there are various practices for documenting progress. In many states, the interdisciplinary team note is a popular and effective practice. The team note is a collaborative note, which includes information from each care plan team member. It reflects information from all disciplines and gives a complete picture of the resident/client’s progress. The team note documents a more integrated picture of the resident/client and minimizes repetitive information found in each disciplines entry.
In some parts of the country, separate progress notes are entered by each discipline. The individual professionals document progress from their perspective. Separate notes allow for a thorough review of progress in each area, however sometimes provides overlapping information. The same information would be entered in either note, depending on your facility practice. The discussion of levels of participation, response to interventions, barriers encountered and outcomes noted could be entered in either the team note or the activity based progress note. Federal regulations do not mandate department specific progress notes, as long as a discussion of progress and participation is noted somewhere in the chart. Again, facility policy and procedure would define where the note is entered.
Episodic Notes, also known as Incident Charting, Focused Notes, or Clinical Entries, are notes entered in response to an event or incident. The note is entered when the incident occurs and focuses on facts and issues related to the incident. Episodic notes should include enough information (such as what the incident was, what the caregiver did in response to the incident, who was informed of the incident, and if the care plan needs to be adjusted) to cover the incident adequately.
Progress notes are an important part of the therapeutic process. They provide on-going information regarding resident/client status, progress and participation in life of the facility. They ensure continuity of care and justification for care and services provided.