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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 8 contact hours
 Documenting resident/client response to interventions
is an integral part of the care planning process. This review
of progress is known as a progress note. There are many regional
variations as to how often, where and what should be documented.
Most nursing homes document review of the care plan on a quarterly
basis, in coordination with the MDS Quarterly. Most medical
day care centers also adopt a quarterly time frame. Facility
policy should define specific practice as to the timing, means
and method of reviewing the care plan. The activity professional
should rely on professional standards to guide appropriate content.
It is also important to keep in mind - the purpose of the progress
note, which is to document how the resident/client is responding
to care and treatment.
The following areas may be included within
any routine review of progress:
*Reassess resident/client for change in functioning compared
to original assessment or last review. Has the resident/client
improved or declined in functioning?
*Review resident/client participation within the activity program.
Focusing on responses to activities and behavior within the
programs is encouraged.
*Review response to any specific interventions, such as room
visits, sensory programs or specialized activities for special
needs. Again, we want to focus on how they are responding to
the interventions, rather than simply stating interventions
were offered.
*Note any barriers to implementation such as resident/client
refusal or unavailability.
In addition to professional standards which
guide our profession, the activity professional who works in
nursing homes needs to reference the guidance for F-248 which
indicates the care plan revision should include:
" Changes in the resident's abilities, interests, or health;
" A determination that some aspects of the current care plan
were unsuccessful (e.g., goals were not being met);
" The resident refuses, resists, or complains about some chosen
activities;
" Changes in time of year have made some activities no longer
possible (e.g., gardening outside in winter) and other activities
have become available; and
" New activity offerings have been added to the facility's available
activity choices. For the resident who refused some or all activities,
determine if the facility worked with the resident (or representative,
as appropriate) to identify and address underlying reasons and
offer alternatives.
Interdisciplinary Notes vs. Department Specific Notes vs.
Episodic Notes
Regionally, there are various practices for documenting progress.
In many states, the interdisciplinary team note is a popular
and effective practice. The team note is a collaborative note,
which includes information from each care plan team member.
It reflects information from all disciplines and gives a complete
picture of the resident/client's progress. The team note documents
a more integrated picture of the resident/client and minimizes
repetitive information found in each disciplines entry.
In some parts of the country, separate progress
notes are entered by each discipline. The individual professionals
document progress from their perspective. Separate notes allow
for a thorough review of progress in each area, however sometimes
provides overlapping information. The same information would
be entered in either note, depending on your facility practice.
The discussion of levels of participation, response to interventions,
barriers encountered and outcomes noted could be entered in
either the team note or the activity based progress note. Federal
regulations do not mandate department specific progress notes,
as long as a discussion of progress and participation is noted
somewhere in the chart. Again, facility policy and procedure
would define where the note is entered.
Episodic Notes, also known as Incident Charting,
Focused Notes, or Clinical Entries, are notes entered in response
to an event or incident. The note is entered when the incident
occurs and focuses on facts and issues related to the incident.
Episodic notes should include enough information (such as what
the incident was, what the caregiver did in response to the
incident, who was informed of the incident, and if the care
plan needs to be adjusted) to cover the incident adequately.
Progress notes are an important
part of the therapeutic process. They provide on-going information
regarding resident/client status, progress and participation in
life of the facility. They ensure continuity of care and justification
for care and services provided.
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