Sample performance improve Notes

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Writing action progress notes can be time consuming but it is an important aspect of documentation. F-tag 248 clearly states that there must be a method in which each resident's schedule of activities is monitored. There are many ways to complete progress notes. Below are two examples of a quarterly progress note.

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Mrs. X
Quarterly Review:

1/20/02

Since her admission on 10/9/01, Mrs. X has pursued an active free time lifestyle. She is alert and oriented to all realms and makes her needs known. She is sociable with both staff and peers and initiates conversations. Her family members are very supportive and visit weekly, providing supplementary reading materials and Mrs. X's favorite foods. Mrs. X is an active participant in daily recreational activities both on and off the unit together with practice programs, adapted corporal games (bowling, basketball, ball games), word games, bingo, trivia, discussion, attractiveness groups, music programs, cooking and crafts. Mrs. X also joined the Resident Council and has attended 1x this quarter. She has been invited to attend the Young Adult Group, however has declined. She enjoys going to the greenhouse for horticultural therapy sessions and the off unit special events. Although a practicing Roman Catholic, Mrs. X states she finds much vigor in attending chapel services of all faiths. Mrs. X enjoys a variety of independent activities including: talking on the phone in her room, listening to music on her Walkman (country and 50-80's music), reading large print books, crossword puzzles and watching movies in her room. Recreation Staff provides movies, crossword puzzles and large print reading materials. Mrs. X has episodes of tearfulness and often dwells on her illness. Recreation staff encourages her to pray, listen to favorite music, or find solace in the greenhouse if Mrs. X does not express interest in joining the group activity. Recreation staff will continue to invite Mrs. X to daily recreational activities and provide supplies for independent pursuits. In addition, Mrs. X will be encouraged to attend the Young Adult Group to spend time with residents of her age group for supplementary preserve and companionship. See care plan whole 3 addressing mood and behavior, for exact interventions. Mary Sunshine, Adc action Director

Mrs. P
Quarterly Review:

9/8/02

Mrs. P remains alert with obscuring and forgetfulness. She is oriented to self and her speech is limited. She responds to easy direct questions by nodding her head or mumbling. Mrs. P is Oob daily in a recliner chair and spends much of the day in the dayroom where she is engaged in recreational activities together with Snoezelen, Five Alive, Sensory and Movement, Music Therapy and adapted reminiscing groups. R/t to poor cognitive status, Mrs. P requires wide aid (i.e. Hand over hand, physical/verbal cueing) to participate in free time programs. R/t contractures of both arms she is provided with U/E and L/E Prom while adapted corporal games and practice programs to allege corporal functioning. while sensory programs, a variety of Recreational techniques are utilized to elicit responses to stimuli including: Aromatherapy for olfactory stimulation; hand massages, textured objects and props (yarn) for tactile stimulation; pictures of interest (cats) fiber optic lights and bubble towers for optic stimulation; ice cream, pudding, flavored lip balms etc. For gustatory stimulation; and music (Italian and singalong) as well as nature sounds, for auditory stimulation. Mrs. P responds to sensory stimulation by tracking objects, vocalizing, smiling, laughing, humming, and tapping feet and hands. She especially enjoys Italian music and the song "O Solo Mio". She also participates in argument and reminiscence groups when asked closed-ended questions. Recreation staff provides one to one sensory programs Prn. family visits are irregular. Recreation staff will continue to provide sensory stimulation to enhance responses to external stimuli and allege ability of life. See care plan whole 2 addressing contractures, for exact interventions. Mary Sunshine, Aac action Assistant

If you're interested in an easier way of completing progress notes you may want to reconsider the following stock from Re-Creative Resources Inc. Recreation progress Note: This one-page form helps you write progress Notes, indubitably and thoroughly. Naturally write phrases or short sentences in the spaces provided. It includes areas such as: One to One Interventions, Group Activities, Responses to Activities, Level of Participation, etc. You also receive the "Components of a progress Note" tool that designates discrete examples in conjunction with the progress Note Form for each type listed. To order this stock visit the re-Creative Resources Inc. Website.

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