12 Tips for Writing Progress Notes

Progress notes are an essential part of the documentation required in nursing homes and assisted care facilities. They record changes that impact on the delivery of care. This information is used to review and update care plans.

Progress notes also provide an important means of communication among staff and reflect the soundness of care delivery in any organization. They are legal documents and should be accurate and plausible and clearly written.

The Role of Activity Professionals in Recording Progress Notes

Lifestyle Coordinators and Activity Professionals often come across situations that call for Progress Notes entries. They interact with clients for a large part of the day and have the opportunity to observe subtle as well as major changes in clients’ health, demeanour, cognitive and physical strength and diminishing abilities.

Here are some examples of grounds for progress notes entries:

• Client suddenly having difficulty to eat independently
• Change in level of assistance required by staff in physical support
• Change in level of support required by staff during activities
• Clients having difficulty swallowing
• Clients having confrontations/altercations with peers
• Absconding
• Non-compliance
• Severe emotional distress
• Depressive symptoms (weeping, anger outbursts, apathy)
• Aggressiveness - Physical and Verbal
• Falls

NOTE: In the case of a fall, make client as comfortable as possible (do not lift or help client to stand up), and send somebody to fetch clinical staff. Stay with client until help arrives.

Important Elements of Progress Notes

Progress Notes entries must be:

1. Objective - Consider the facts, having in mind how it will affect the Care Plan of the client involved. Write down what was heard or seen or witnessed, what caused it, who initiated it.
   
   
2. Concise - Use fewer words to convey the message.
   
   
3. Relevant - Get to the point quickly
   
   
4. Well written - Sentence structure, spelling, and legible handwriting is important

Use your critical thinking to analyze, assess and reconstruct the situation. Consider that everybody sees the situation from their own point of view. Ask questions:

• What happened?
• Who is involved?
• What was the cause, motive?
• Was it witnessed? If ‘yes’ : How did it happen?

These questions will likely be answered in a subjective manner. Listen attentively and then use your reasoning to be objective and draw conclusions based on facts. Provide recommendations if needed.

Structuring entries:

Entries should also be in the active voice for more engaging reading. However, when referring to what other staff did for clients use the third person and start the sentence as in a procedure: Staff monitored, escorted, observed, supervised, assisted, guided, and so on.

12 Tips for Writing Progress Notes

1. Progress Notes should be read at the start of each shift, so staff have a clear understanding of what kind of support will be required.
2. Write clearly and legibly, then sign, time and date entry.
3. Make entries in black pens only and don’t use whiteout.
4. Refer to previous entries for continuity.
5. Write occurrences as soon as possible after the event/situation.
6. If entry is done electronically, make sure it refers to you and no one else.
7. Don’t use jargon, and make sure your spelling is correct.
8. Avoid abbreviation and acronyms, unless approved by management.
9. If recording a lengthy occurence write ‘continues overleaf’ at the end of page and 'Continued from previous page' on the new page.
10. Don’t tamper with entries, if a mistake is made cross it out and continue.
11. Acknowledge that Progress Notes contain confidential information and should be kept in a secure location to be used/seen by authorized staff only.
12. Remember - if it is not written down, it didn’t happen.

Examples of Progress Notes Entries

Subjective examples - the WRONG way

Miss Jones was crying and carrying on because Mrs Herbert had 'stolen' her handbag. Mrs Herbert had hidden the handbag behind her seat and was shouting and swearing telling everybody the handbag was hers. We gently took the weeping Miss Jones away and gave her a cup of tea. Later, at lunch time Mrs Herbert walked to the dining room forgetting the handbag on the chair. We then handed the handbag to Miss Jones and she was very happy.

Edna, Mrs Day’s daughter was furious when she arrived to pick her up to go to the circus and she wasn’t ready. When staff arrived for a new shift there was no message or indication Mrs Day had to be ready by 2:00 pm. Edna was running late, and became even more enraged when she realised staff still had to shower Mrs Day. She kept grumbling that she had phoned ages ago, and that it was just not good enough. As they finally left, Edna mumbled to staff: "Thanks for nothing".

The above entries are not professionally done;

• They contain jargon,
• Assumptions were used ,
• They are too long,
• Unnecessary information were provided.

Objective examples - the RIGHT way

Miss Jones was visibly distraught looking for her handbag. Mrs Herbert had it, but using inappropriate language refused to give it back. Miss Jones was escorted away, consoled, and offered a hot drink. By lunchtime the problem had dissipated.

Edna arrived to pick up her mother Mrs Day, as she had requested last week, but she wasn't ready. She was very upset. Nurse in Charge apologized to Edna for the inconvenience and assured her it won’t happen again. Subject placed on agenda for next Staff Meeting.