How to write Progress Notes

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Progress Notes are a journal of care delivery and health information. They are important, brief narrative entries written by health professionals, care and recreation staff to record negative and positive occurrences relating to residents. Progress Notes are also used to record situations regarded as irregular, and residents’ response to lifestyle issues. Progress Notes can be handwritten or typed.

Progress Notes are written to supplement care documentation so that quality care is continuously improved. It enables care staff to re-assess the needs of residents, make changes to their Social Profiles and seek appropriate interventions for Care Plans. Entries can encompass many facets of residents’ lives:

• Weaning interest in social activities.
• Reaction from medications.
• Sudden change in health.
• Confrontations with peers.
• Results of therapeutic interventions.
• Change in behaviour.
• Absconding.
• Intrusiveness.
• Poor participation in activities due to deteriorating health.
• Errors

If you are lucky enough to work in a facility where Progress Notes are recorded electronically, you will find that each entry is identified by user, title, date and time, saving you time.

To be effective, Progress Notes must be objective: you report information that is measurable and observable. In other words, information that you have seen, heard, tasted, witnessed or initiated. Subjective documentation is not recommended it cannot be evaluated. Subjective entries are those which reflect your opinion, judgement and assumption.

It is also important to keep Progress Notes short, a simplified version of what happened.

It is suggested that staff read existing Progress Note entries to be aware of changes and exceptions to medication, diet, occupational therapy, physio therapy, dentists, medical practitioners, behaviour assessment, appointments, and recreation therapy.

Integrated Progress Notes indicate continuity of care from a multidisciplinary team of health and care staff.

Here are 4 pages of samples that will help you get started writing objective, concise and professional Progress Notes.

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