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Monireh 17th Dec 2014

Posted on the Forum

Hi all, i was wondering if I could get some help on Progress notes. I am mostly writing the same info for all residents. I welcome any ideas.
Thank you
Dene 20th Dec 2014
Hi Monireh. I am Diversional Therapist and Manager of a team of 4 and approx 50 volunteers at a facility in New Zealand. I used to use a Progress Note system but found that my staff spent far too much time doing notes when they could of been with residents. In the end I made up a tick sheet that is used on a monthly basis, it has all the main activities that we do plus areas for additional activities if needed. Everhy resident has their own tick sheet for the month and the back has an area for exceptions. If anything out of the ordinary happens, or they do a face to face etc a brief note is left. This system has worked really well for our facility for over 3 years now and we have passed audit with flying colours every time. Hope this has been helpful. Kia Ora, Dene
Judy 27th Dec 2014
Hi. Monireh. Progress notes should be. written on what you observe, any new responses positive or negative during activities or any interaction between resident any other people staff,family,other residents.These must be what you observe,not what someone tells you and must be done within twentyfour hours of it happening.if not documented it didnot happen,that way patterns can be colated.I had 66 residents to do progress notes on monthly,or more often if somethingcould ccou needed recording,so last job of the day was to record any thing of note, inform reg nurse if needed,towards end of month go through all progress notes and complete any not already done,remembering that saying someone loved the new craft is not acceptable someone participated with limited assistance to complete the soap making is the proffesional way to reccord.reading this back sounds bossy maybe I could help better with more info. Judy

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