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by Debbie
Hommel, ACC, CTRS
See
DH Special Services Independent Study
Documentation
Techniques for the Activity and Recreation Professional
NCCAP approved 10.5 contact hours
 In addition to regular entries documenting
progress toward care plan interventions, the activity professional
may need to enter episodic entries. Episodic entries are also
known as focused charting, clinical notes or incident charting,
depending your facility policy and protocol. In all cases, such
notes are entered in response to something that occurs in between
the time frames for routine progress note charting.
In nursing homes, episodic charting substantiates
changes to section N of the MDS, for quarterly reviews and necessary
changes to the care plan. To arrive at the care plan meeting,
with significant changes to the MDS noted without any substantiating
documentation is not good practice. Additionally, episodic charting
shows progress (positive or negative) toward defined problems
(behavior, response levels, and health issues) as they occur
throughout the quarter.
One big question is when should I document
an episodic note? The following is a listing of suggested
incidences to consider for episodic notes:
-Demonstration of unusual or out of the ordinary behavior, difficult
or negative behavior which may not be part of the typical nature
of resident. On the other side of the coin, a ceasing of a particular
behavior which is the "norm" for resident should also be noted.
Any change in behavior that is noticeable should be documented.
Chances are the nurse is documenting such changes. However,
in terms of behavior management, the more documentation that
is noted, the better and the activity professional can offer
significant information regarding the success or lack of success
of non-pharmacological interventions and responses.
-Significant responses to a targeted intervention
should be noted, as relevant. A resident who doesn't respond
to sensory approaches or suddenly responds to a cue is significant.
A resident remains awake through a program when generally they
generally sleep is significant. Being able to complete a task,
when they were never able to complete a task or focus n a task
is significant.
-Negative responses to targeted interventions
should be noted. When the activity professionals' efforts to
engage the resident in the written interventions are met with
consistent refusal, and obvious negative responses, there should
be some documentation. When the resident usually attends or
pursues activities and suddenly stops or becomes reluctant,
that should be noted. To wait until the quarterly note is due,
to document refusals or difficult responses is not good practice.
-When providing some sort of device or approach
previously requested or noted in the care plan, it should be
noted that it was provided and the initial response. Specific
cases may include noting that a cassette player was requested
from the family and was provided; a special craft project was
found for the resident and provided; specific 1-1 activities
were requested or defined and provided; and any specific interventions
for a behavior. -Any aggressive act or encounter in an activity
or during a 1-1 visit should also be noted.
Another question that comes up is- What
should I include in the note?
-Define the incident or episode; describe
what actions, responses and behaviors occurred.
-Include when and where the incident, episode
or behavior occurred.
-Include what you found on the scene, if
you were first to arrive to the incident.
-Describe what care was provided to the resident,
upon arrival to the scene and after the incident occurred.
-Include any resident comments, statements
and responses to incident, intervention or episode.
-Note who was notified of incident.
-Include any preventive steps to be introduced
or changes to the plan of care, to prevent incident from occurring
again.
Some final helpful hints regarding documentation,
in general.
-Use behavioral language. Describe the resident's
actual actions, responses, reactions, facial expressions, body
language, posture, and general movement as opposed to labeling
response.
-Ensure consistency of information. This
is not to say your entries must agree with all others, however
if your perception and description is different from other professionals,
be sure to explain what you mean and how this impacts upon the
consistency of observations. Documenting from a behavioral perspective
supports your observations.
-Use meaningful versus vague phrases. Stick
with behavioral and observable language. Vague phrases include
"seems" or "appears". If the resident is crying, you would note
they were crying rather than note "resident seems sad". Instead
of saying "resident seems to enjoy group activities", it is
more effective to note "resident shows signs of enjoyment at
morning social through smiling, interacting with peers and verbalizing
actively during discussion time".
-Be accurate. Don't document anything you
are unsure of and did not directly observe or encounter. If
documenting what another professional reported to you, note
that it was reported by that individual.
-Follow medical record guidelines. Remember
grammar, spelling, legibility, and corrections.
-Follow facility policy regarding each entry.
Note department, focus, time, date, full name, job title or
certification.
-Consider follow up notes as pertinent. The
activity professional is an important member of the treatment
team. Documentation, and our role in the process, plays a significant
part of fulfilling our responsibility.
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