How to write Progress Notes

Progress Notes are brief narrative entries written to record negative and positive events relating to residents. They are also used to record situations regarded as irregular, and residents’ response to lifestyle issues.

Progress Notes are written to supplement care documentation so that the quality of care can be continuously improved. They enable staff to re-assess the needs of residents, make changes to their Social Profiles and seek appropriate interventions for Care Plans.

What should be recorded as a Progress Note?

Progress Notes can encompass many facets of residents’ lives:

• Diminisghing interest in social activities
• Reactions from medications
• Sudden change in health
• Confrontations with peers
• Results of therapeutic interventions
• Change in behaviour
• Absconding
• Intrusive behaviour
• Poor participation in activities due to deteriorating health
• Errors

How to record Progress Notes

Progress Notes can be handwritten or typed. If you are lucky enough to work in a facility where Progress Notes are recorded electronically, you will find that Progress Notes are quick to access and easy to record, saving you valuable time.

Be Objective and Brief

To be effective, Progress Notes must be objective: you must report information that is measurable. You should record situations that you have witnessed or initiated. Subjective documentation is not recommended as it cannot be evaluated. Subjective entries are those which reflect your opinions or assumptions.

It is also important to keep Progress Notes short; they should be a simplified version of what occured.

• Objective phrases are those based on observation and presented as facts.
• They should not be written based on prejudices or influenced by emotional outpour.
• However subjective words such as: eager, agitated, enraged, restless and so on, may be used in Progress Notes to describe your impression of the resident.
• Your description is of clinical significance to the RN or doctor.

Always read through existing Progress Notes

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, behavior assessment, appointments, and recreation therapy.

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

11 Progress Notes Samples - Good & Bad:

1. Long version - the WRONG way

Staff were escorting Mrs Bow to the dining room when she saw Mrs Allen wearing a yellow cardigan. Mrs Bow started weeping, saying repeatedly: ‘it is my cardigan’. She then insisted on going back to her room and refused to eat. Staff established that the cardigan had no name tag.

1. Short version - the RIGHT way

Mrs Bow was visibly upset when she assumed Mrs Allen was wearing her cardigan, a fact that could not be verified by staff as there was no name tag. Mrs Bow declined lunch after the incident.

2. Long version - the WRONG way

This evening I was passing by the dining room when I saw the RN administering medication to Mr Casals. However, as soon as the RN turned her back Mr Casals spit his tablets out into his hands and placed them quickly in his pocket. I went and found the RN to inform her.

2. Short version - the RIGHT way

At lunch time I observed Mr Casals taking tablets from his mouth and placing them in his pockets. RN informed.

3. Long version - the WRONG way

Sitting in the recreation room, Mr Tiller became very agitated and red in the face and used abusive language towards Mr Sims when he saw him walking away with his walker. Staff told Mr Sims that the walker did not belong to him and he returned it.

3. Short version - the RIGHT way

Mr Tiller became distressed and used improper language when Mr Sims mistakenly took his walking aid. He settled down after it was returned.

4. Long version - the WRONG way

I escorted Mrs Jenny Ho to the toilet but when we got there it was occupied by Mr Gill. He stayed there too long and Jenny couldn’t hold on anymore and wet herself. Staff took her back to her bedroom so she could change her clothes.

What’s wrong with this information?
“Stayed too long” - compared to what? When was a time limit set up to go to the toilet? By whom? “Wet herself” - How do you know? Maybe Jenny has an ‘UTI’ (urinary tract infection). Maybe she drank too much liquid. How about this:

4. Short version - the RIGHT way

Staff escorted Jenny Ho to toilet but she didn’t make it. Jenny was escorted away to be attended to.

5. Long version - the WRONG way

Ivy was waiting for her lunch when she started calling; “nurse, nurse”. Lindy, sitting nearby showed Ivy her walking stick and shouted out that she would bash her over the head if she didn’t shut up.

5. Short version - the RIGHT way

Ivy called the nurse repeatedly at lunch. Lindy resented it and threatened Ivy with her walking stick using improper language. Staff attended to Ivy.

6. Long version - the WRONG way

Linda’s name was placed on the list for the bus outing “Fish & Chips on the Bay” by her relatives. When we got there Linda wouldn’t stay seated, walking away all the time without her walking stick. Staff had to be with her the whole time afraid she would fall and break a leg. The problem was that the other staff had to look after another 6 residents on their own. It was very hard and staff agreed that Linda should not come on bus trips anymore.

6. Short version - the RIGHT way

Linda went on the bus trip but became non-compliant with her walking aid. One-to-one attention was necessary for safety reasons. Linda’s relatives will be invited to join bus outings in the future.

7. Long version - the WRONG way

This morning at the gardening activity John called Bill ‘names’ and wheeled himself towards him to hit him. Bill was furious and did the same waving a small shovel in the air threatening to ‘kill’ John. When staff asked what the problem was John said Bill had ‘pinched’ his shovel but Bill said John had taken all the planting pots and left him with none. Staff sat them on opposite ends of the table and kept an eye on them for the remainder of the session.

7. Short version - the RIGHT way

At the gardening session this morning staff had to separate John and Bill as they exchanged expletives and threatened each other. The reason for the altercation was not established.

8. Long version - the WRONG way

This morning Denia asked staff to take her home because her mother was waiting for her. She was holding two shopping bags full of clothes and an umbrella. Staff tried to tell her that she should wait until her family came to take her but she wouldn’t listen. She started to cry and walked the in the direction of the front door. She said her mother would be terribly worried if she didn’t come home. Staff had to call for assistance to take her back to her room.

8. Short version - the RIGHT way

Denia was delusional and rather distressed this morning, crying and packing her clothes. Staff spent extra time with her to console and reassure her.

9. Long version - the WRONG way

Martin was very difficult this afternoon asking staff to put more sugar in his coffee. Staff explained to him that three ‘splenda’ (artificial sugar) was what he usually took because he is a diabetic. He said he wanted more and shouted abuse at staff. Staff had to go and ask the RN for permission and the RN said staff could give him one more sugar.

9. Short version - the RIGHT way

This afternoon Martin became enraged and used improper language with staff saying that his drink didn’t have enough sugar. Staff consulted the RN and Martin was given extra sugar.

10. Long version - the WRONG way

This morning Jean was sitting on the table for craft when staff noticed that Irene came from behind and took Jean’s handbag. Staff tried to rescue the handbag before Jean noticed it but it was too late; Jean called Irene a ‘thief’ and demanded her handbag back. Irene was persuaded to give back the handbag when staff presented her with another one.

10. Short version - the RIGHT way

Irene behaved intrusively this morning by taking Jean’s handbag. Jean used inappropriate language but calm was restored when staff offered another handbag to Irene.

11. Long version - the WRONG way

Myrtle was agitated and upset with the hairdresser because her name was not on the list for a hair-set. The hairdresser explained to Myrtle she had her hair set only fortnightly but Myrtle didn’t want to hear it, she wanted her hair set. Myrtle was making a scene and staff had to remove her from the hair salon. Staff consulted the RN who suggested a phone call to Myrtle’s family to ask for permission to have her hair set again. This was done and peace restored.

11. Short version - the RIGHT way

Myrtle was confused thinking her hair appointment was today. She became distressed and at the RN’s suggestion Myrtle’s family was consulted and she had her hair set which made her very happy.

Need more examples?

Related: 12 Tips for Writing Progress Notes