Writing activity progress notes can be time consuming but it is an important aspect of documentation. There are many ways to complete progress notes. Below are two examples of a quarterly progress note.
Since her admission on 10/9/01, Mrs. X has pursued an active leisure 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 additional reading materials and Mrs. X’s favorite foods. Mrs. X is an active participant in daily recreational activities both on and off the unit including exercise programs, adapted physical games (bowling, basketball, ball games), word games, bingo, trivia, discussion, Beauty 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 strength 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 additional support and companionship. See care plan number 3 addressing mood and behavior, for specific interventions. Mary Sunshine, ADC Activity Director
Mrs. P remains alert with confusion and forgetfulness. She is oriented to self and her speech is limited. She responds to simple 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 including Snoezelen, Five Alive, Sensory and Movement, Music Therapy and adapted reminiscing groups. R/t to poor cognitive status, Mrs. P requires extensive assistance (i.e. hand over hand, physical/verbal cueing) to participate in leisure programs. R/t contractures of both arms she is provided with U/E and L/E PROM during adapted physical games and exercise programs to maintain physical functioning. During 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 visual 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 discussion 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 maintain quality of life. See care plan number 2 addressing contractures, for specific interventions. Mary Sunshine, AAC Activity Assistant
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