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.
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.When should you write a Progress Notes Entry?
Here are some examples of grounds for progress notes entries:
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.
Progress Notes entries must be:
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:
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.
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.
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;
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.