12 Tips for Writing Progress Notes

12 Tips for Writing Progress Notes

Found In: Activities Articles

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 and are used to review and update care plans.

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 and are used to review and update care plans.

In this article we cover:

  • The Role of Activity Professionals in Recording Progress Notes
  • Important Elements of Progress Notes
  • 12 Tips for Writing Progress Notes
  • Exaples of Progress Notes - good and bad

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Solange 18th Apr 2018
Hi Lorraine, here are two examples of a monthly Care Plan Evaluation/Update. In my days we did not do it monthly, instead we did it every quarter.

Anastacia Dunn -
Anastacia continues to attend group activities daily. She has a good disposition but requires constant supervision to avoid intrusion on peers. She particularly enjoys craft with staff assistance. Volunteers take Anastasia to the Greek Club and a Greek religious service once a month. Anastacia has developed a rather noisy behaviour in the late afternoons; she calls staff incessantly in a loud voice and has to be taken away from the recreation area to calm down. She has started attending Tai Chi on a passive basis as she cannot follow the leader. Her family visit every Sunday and bring home-cooked food which she loves. Anastacia's Care Plan has been evaluated and updated with new interventions.

Albert Carr -
Albert's Care Plan interventions remain suitable to his needs. Albert unfailingly attends daily group activities and engages in whatever activity is going on. He has good humour and enthusiasm for life and is slowing getting used to the wheelchair. Albert has good rapport with staff and enjoys talking about history and his forebearers (Irish). He has developed stiff fingers and cannot do puzzles as he used to, he now enjoys doing the 35 piece puzzles. Albert's good friend Hugo has not visited due to ill health, he misses him. He hsas developed a fear of going out since his myocardial infarction and refuses to go on bus trips which he so enjoyed in the past. Staff are supportive but unable to encourage him to change his mind and come along.
Amtul 17th Apr 2018
Would love to see some of your quarterly notes example if possible can you please post one or two examples. Thanks in advance
Solange 18th Apr 2018
Hi Amtul, I agree with Debbie. Start the quarterly with a concise overhaul of the last quarter so as to compare to the current quarter. You should then proceed with a short paragraph about the Physical, Social, Emotional and Spiritual needs of the resident in question.

Here is an example - Norma Steenes 86 years old - Croatian

Norma's usually calm and cooperative disposition has been of late disrupted by cognitive deterioration evidenced by confusion, lack of focus, and disorientation. She continues to attend seated exercises although she loses concentration and engages her neighbour in conversation during sessions. Activity attendance has diminished; she often stands up and leaves the group saying she is 'running late' only to come back a few minutes later. Norma has many friends and enjoys their company. She likes being useful and follows staff asking if she 'can help'. She talks Croatian with peers and staff more than ever before. Norma is found asleep in other resident's rooms at least once a week. Norma takes pride in her appearance and goes to the hairdresser fortnightly. She can get very distressed thinking that people are 'stealing' her belongings and staff spend extra time consoling and reassuring her. Norma attends Lutheran Service weekly. Gardening is one of Normas preferred activities. Her Care Plan has been reviewed and new interventions developed.
Rehana 16th Apr 2018
Thank you.
Need more information on residents who are on ACFI.
Daily progress notes pls.
Solange 18th Apr 2018
Hi Rehana, despite Lifestyle and Activities not being a category included in the ACFI, audits are certainly very interested in lifestyle matters and leisure activities available to residents. They want to establish if functional competencies require extra attention from staff. During an ACFI audit, ponder on what level of assistance do clients rely on staff in order to attend activities? Is escorting needed? How much extra time is needed for emotional reassurance? meals supervision? attending church? walking? Has he/she lost interest in helping planning activities that matter to them? Is there an activity he/she used to enjoy but can no longer do it? Has attendance drop due to health issues? The audits want to know if the client's application for extra funding is warranted.
Helen 10th Apr 2018
Love these examples off progress notes , thanks
Debbie 10th Apr 2018
I am training a new staff person and will utilize some of the points here. Thank you. I love this site. In my quarterly progress notes I have a certain order. I write what the last quarter goal was, how it was met, especially enjoyed activity, observations about behaviors/enjoyment of activities, anything I have done for the resident, new goal, and how many programs attended or 1:1's for the three month look back period. This allows me to see the trends of participation.
Megan 10th Apr 2018
wow, that would be a very clear picture to charting the stats and what needs to be improved etc.
Lorraine 10th Apr 2018
Thank you.
Would love to see some examples of monthly evaluation of activities.