12 Tips for Writing Progress Notes

12 Tips for Writing Progress Notes

Found In: Activities Articles 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.
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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.

When should you write a Progress Notes Entry?

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.

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Comments   Post a Comment

Vivian 11th May 2019 Executive Director
Can you please give me some suggestion. I am new have 14 clients were unaware that quarterly review needs to be completed. What do you recommend to rectify my problem? This does not include past clients.
Lalaine 2nd Jun 2018 Life Style Officer
This site is really helpful and useful. I am so thankful and glad that I joined this site. People here were great!!! Love you all
Talita 4th Jun 2018
Awww that's so lovely to hear Lalaine! Thanks for your feedback, we really appreciate! Love the community here too, everyone is so helpful and supportive! All the best x
Olwyn 7th May 2018 Diversional Therapist
Hello Amtul, I Hope this helps also.

Care plan: Leisure and Lifestyle
Name: xxxx
D.O.B.
Room No.25

xxx ambulates well unaided and always enjoys a chat. xxx does not speak another language except English and does not require an interpreter. Xxx t has regular visits from staff, family and volunteers and socialises with others in the common areas, such as in her unit, dining room, facility, gardens, and walkways on occasion. xxx is not at risk of social isolation. xxx has a quiet and gentle nature and is most willing to not only participate but to contribute to attended activities in a practical way. xxx is not a social person, but is compliant and eager to please, thrives on 1:1 interaction, always willing to engage with staff, other residents and visitor's to the home xxx privacy is respected at all times. Staff and visitor's knock before entering her room.
Independence/Choice and decision making
xxx enjoys being actively involved, independently choosing to participate in activities of her choice. Staff support xxx choices by allowing xxx to choose which activities she would like to do. xxx participates according to the activities program, requiring a reminder and an escort to the Activity room or to the courtyard some time before the activity begins from L&L Staff and volunteers to attend.. xxx independently chooses to have quiet time or a rest in her room on occasion, or to go for a walk around the facility and into the gardens on the walking path. Xxx is definite in her likes and dislikes and is able to articulate her needs. Xxx attends Resident & Relatives meetings. xxx enjoy 1:1 time and is given the opportunity to voice any concerns she may have during 1:1 chats in her room. xxx receive social and emotional support in xxx room, or in the Activity area as documented in activities log, and folder during 1:1 visits from L&L staff and volunteers.
Group Participation:
xxx attends a range of activities of her choosing, and participates effectively, remaining engaged throughout the duration of the activity. Her involvement in the L& L program activities suggests a balanced lifestyle, and all risks are assessed and considered safe. xxx reads her monthly program on the notice boards and the weekly activity plan in her room in her room, which the DT provides. xxx is capable of self-initiating to some activities on occasion but prefers a reminder and an explanation of the activity. xxx enjoy physical activity, in varied forms but is particular which activities she attends, eg . Disliking bowling but prefers skittles. No member of the xxx family or xxx have requested or suggested any further activities to cater for xxx needs or interests. an xxx family are happy for xxx to spend time contentedly amusing herself in her room as this is an xxx pattern of behaviour for many years. Dt did suggest that xxx1:1 time with volunteers and staff be increased to prevent possible social isolation.
Spiritual Identity:
• xxx attends religious, spiritual and pastoral care routines and continues to celebrate Christmas, Easter, and birthdays according to the program plan.
• and enjoyed the busy festivities of Christmas and the leadup to Easter

Complaints and Compliments:
During xxx evaluation meeting, xxx was reminded of the complaints procedure and is aware of her rights. xxx has not asked for an advocate .xxx has no complaints. xxx is pleased with staff in general and said xxx is happy.
Meaningful Contribution:
xxx has a role sorting the magazines in the activity room. Risks are assessed before xxx takes on any tasks.


NEXT REVIEW: September, 2018

Olwyn N (DT)
17.06.2016
Olwyn 7th May 2018 Diversional Therapist
Here is one example of a quarterly review.
Over the past months, has been involved in 162 activities, 60 Individual visits from family, friends, staff or volunteers.
Before xxxx came to live at the home she lived a quite, almost solitary existence. Her main interests were nature, and various pets on a rural setting.
xxxx enjoys reading magazines, listening to music and small group activities and sitting in common areas. However, is reluctant to attend large group activities.
DT has invited xxxx ladies group afternoon teas. xxxx has attended on most occasions and has interacted socially with the other ladies.
xxxx has not spoken to DT staff in relation to emotional support but often becomes anxious and needs comfort and reassurance.In particular, she worries about her animals, and whether she has left a tap running in her bathroom.
xxx or her family has not asked for an advocate.
xxx still enjoys attending many activities and her activity reports reflect a balanced lifestyle.
xxx has regular visits from her family.
Xxx is always welcoming of a conversation, but patience is needed to ensure xxx can respond and interact.
xxx also engage in social activity with other residents in the activity room, quiet areas, courtyard and facility and is not at risk of Social Isolation

Her privacy is respected at all times by visitors, and staff by always knocking before entering her room.
. DT provides a weekly individual activity plan and also places a copy on the corridor noticeboards.
Amtul 23rd Apr 2018
Thank you for sharing the examples.
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 Diversional Therapist
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.
.
Amtul 22nd Apr 2018
Thank you very much!
Solange for sharing the examples and your kind advice. Much appreciated.
Rehana 16th Apr 2018 Carer
Thank you.
Need more information on residents who are on ACFI.
Daily progress notes pls.
Solange 18th Apr 2018 Diversional Therapist
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 Social Care
Love these examples off progress notes , thanks
Debbie 10th Apr 2018 Recreation Therapist
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 Therapy Assistant
wow, that would be a very clear picture to charting the stats and what needs to be improved etc.
Lorraine 10th Apr 2018 Lifestyle Coordinator Riverside
Thank you.
Would love to see some examples of monthly evaluation of activities.
Solange 18th Apr 2018 Diversional Therapist
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.
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