Progress Notes cont’d

1. HPR 451 Progress Notes cont’d

2. Content of Progress Notes • What is significant??? • Progress toward attainment of client goal • Regression from attainment for client goal • New pattern of behavior • Consistency of behavior • Verbal information provided by the client • Successful or unsuccessful attempts at a task • Appropriate/Inappropriate interactions with staff, peers, visitors, etc

3. Content of progress Notes (cont’d) • Initiative with actions, ideas, problem solving, decision-making • Follow-through or lack of follow-through with commitment • Overall, general behavior and participation patterns, specific behavioral cues, and environmental cues are all potentially significant information to be included in progress notes.

4. Attendance and Participation • Significance of Attendance and Participation will vary from client to client • Attendance is not indicative of participation • Ask yourself and perhaps document • Did the client attend voluntarily? • Did the client respond to staff or peer requests? • Did the client merely observe the activity? • Was the client actively participating in the session? • Did the client assume a leadership role?

5. Ex: Incomplete and More Complete Progress Notes • Incomplete Progress Note • 3/28/10 Pt. attended cooking class. • More Complete Progress Note • 3/28/10 Pt voluntarily participated in Friday’s cooking class. He offered three appropriate suggestions to help organize other pts. assigned to different tasks, completed his task, and voluntarily offered to assist with cleanup.

6. Physical cues for documentation Dress – sloppy, neat, formal, clashing colors, informal, disarrayed, soiled, filthy, stained, conservative, stylish, brightly colored, darkly colored Hygiene and Grooming – clean, dirty, unbathed, uncut hair, well-scrubbed, unshaven, meticulously groomed, messy hair, body odor, unkempt Posture – slouched, sat or stood erect, arms crossed, rigid, slumped, legs crossed Movement – jerky, fast, slow, tapping foot, wringing hands, shuffling feet, awkward, clumsy, agile, graceful, excessive movement, hyperactivity, twitches

7. Physical Cues cont’d • Social Distancing – touching, moving away from, ignoring, moving closer to • Face – lips quivering, jaws clenched, eyes red, maintaining eye contact, cheeks flushed • Mood and Affect – Lively, neutral, normal, blunted, flat, stable, labile, defensive, calm, sad, hostile, guarded, distant, evasive, cooperative, open • Speech – talkative, verbose, clear, slurred, monotonous, dull, slow, fast, even, jerky, halting, loud, soft, inaudible, whispering, silent • Orientation – oriented/disoriented to person, place, time, event (oriented x3, x4)

8. Environmental Cues • Weather conditions • Temperature • Surrounding objects (cluttered room, open space) • Social patterns –(quiet small group discussion vs. loud, active competitive game) • Positioning(front of room, alone, behind table) • Setting(indoors, outdoors, familiar areas)

9. Ex: Progress Note with Physical and Environmental Cues • Incomplete Progress Note • 5/30/10 Pt. voluntarily participated in holiday outing • More complete Progress Note • 5/30/10 Pt. voluntarily participated in holiday outing. Although the weather was cold and rainy, pt. arrived in his cut-offs and dirty t-shirt.

10. Discharge and Referral Summaries • Usually the Final component • Move from inpt to outpt care affects whether or not they are used in a facility • Each facility will have guidelines for how written and how used • “Begin making plans for discharge the day the pt. is admitted” TR focuses on how treatment was used during admission or outpatient tx to improve functioning and how it will carry over after d/c

11. Therapeutic Recreation D/C Summaries • Major Client Problems or Goals the client achieved while receiving TR tx and services • Services Received by client – summary of types, frequency, duration of client’s involvement • Client’s response to functional intervention (Tx), Leisure Ed and Rec Participation Svcs – Summary of highlights from previously documented assessments and progress notes

12. Post Discharge Plan • Remaining Problems or Concerns – Functional intervention and Leisure Ed are rarely complete at time of discharge. What, if any, TR concerns regarding post discharge related to leisure functioning? • Plans for post discharge leisure involvement – Clients should be involved in developing the plan. Based on client’s needs and abilities. Define client’s responsibilities and agency responsibilities.

13. Incident Reports • Each agency will have forms and procedures – Risk Management • client injury or death • broken equipment (van lift) • client elopement • medication error • child abduction • patient falls

14. Incident report info • When and where did incident occur • Findings at the scene • Care of the client • Client’s comments • Who was notified • What preventive steps were taken?

15. Incident Report Guidelines • Write objectively – facts – what was seen, heard and what actions taken • Include only essential info – include time, place and physician notified • Avoid opinions • Assign no blame • Avoid hearsay and assumptions – each staff member who witnessed or was involved should complete an incident report • File report properly