Posted by Terry (67.235.113.193) on October 12, 2003 at 22:37:49:
In Reply to: Re: Need copy of Progress notes/ Attendent sheets posted by Rita on October 12, 2003 at 06:49:18:
I'm am also looking for the same thing.
: : Here is an example of how we write progress notes. The initial progress note or assessment should include the following:
: : 10/06/03 Assessment Kathi Roberts was admitted to Lasata (your facilities name) on 9/26/03. She is alert and oriented x's 3, walker mobile, has good hearing, vision and dexterity. Kathi converses well with a good long and short term memory. Family support includes one son, one daughter and her husband. In her past Kathi enjoyed playing foosball, volleyball, guitar, piano, rang bells in her church choir, wrote music and played french horn. She attended church on a regular basis and was involved in several groups through her church. Her present interest include music of all kinds, attending church services here, vists from her family, crafts, bus trips, specials, parties, exercises and trivia. Since she is new to our facility, she needs to establish a level of activity participation. We will invite her daiy, provide her with the activities she stated an interest in and assist her to and from as needed to find the location of the programs. Activities will encourage Kathi to attend daily programs in order to establish a daily level of activity participation. Then sign your name.
: : The next progress note need to include the following:
: : 01/06/04 Kathi remains alert and oriented x's 3 (if she didn't, say how she is oriented now). She has established a level of activity participation of daily. Her attendance includes Music, special programs, trivia, bus trips, church services, one on one visits and her family visits weekly. We will continue to provide Kathi with the programs she enjoys and praise her high level of participation. Her care plan has been changed to reflect this change. Sign off.
: : If there is a change in her dexterity, vision or moblilty you need to state the change, why it occured, and how it affects her activity attendance. Kathi
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: Kathi,
: I liked your Progress note you did for Terry, It was very helpful. But I would like a sample of one who was a little more confused, and refused to attend activities. I have so many who want to stay in their rooms. Or is unable to attend activities. Thank you for your help. Rita