Overview on progress notes
Progress notes are a form of clinical documentation that records details about a patient’s diagnosis and treatment plan. Progress notes are often shared between other healthcare providers, insurers, and lawyers to ensure that patients receive the best quality of care possible. While specific details included will depend upon the professional modality, progress notes generally have the same information. Formatting structures that highlight vital aspects in progress notes, including SOAP and DAP, can streamline your notes and improve your clinical record documentation.
What are progress notes in aged care?
Like any other healthcare profession, those who work in aged care must maintain their clinical documentation by writing progress notes. These can be used to assess the effectiveness of treatment and the achievement of any objective targets.
Support workers and nurses write progress notes in aged care following the end of their shift. Medical progress notes are essential communication tools used between other staff, healthcare providers, and family members to ensure that clients receive optimal care. Briefly, progress notes in aged care should include:
- References to a client’s treatment plan and any changes noticed.
- Symptoms or signs were observed in the client.
- Whether the client has achieved their target goals or objectives.
- Any relevant events or behaviors observed during the shift.
What is the purpose of progress notes in aged care?
Progress notes are a critical element of aged care work for a multitude of reasons.
Legal Context: Progress notes are legal documents that can often be used in legal proceedings. They can be used to determine whether the treatment of a client was ethical and can also protect aged care workers. Aged care workers must document any incidents or allegations in their progress notes and make external reports if necessary.
Sharing Information: Well-maintained and adequate clinical documentation is often shared between family members and other healthcare providers. This streamlines communication and ensures that every person in the client’s life can contribute to their wellbeing as effectively as possible. They can also be used as handover notes for staff working the next shift.
Tracking Progress: Progress notes detail the objectives and goals set for the client and whether these goals have been achieved. They can be used to determine whether a new treatment program or plan should be established and to identify achievements.
Service Delivery: Clinical documentation fundamentally serves as proof of service delivery. Progress notes indicate whether the service’s principles, standards, and policies have been applied to the client.
How to write nursing progress notes in aged care?
Different formatting techniques and guidelines have been constructed to assist with the process of writing progress notes. One of the most commonly used formats is SOAP, which separates progress notes into four sections: subjectivity, objectivity, assessment, and plan. A more detailed example of writing SOAP notes can be found here. Progress notes can be written in hard copy or using an online clinical documentation system. They must be safely stored in a HIPAA-compliant manner.
While there are differences in how you choose to write your progress notes, much of the content will be the same. Progress notes are not designed to be step-by-step stories of a client’s entire day but rather a snapshot of progress and any behavior that may be unexpected. We have summarized some of the information that is required in all aged care progress notes:
Essential Details: Your name, the client’s name, the date, and the time must be included in all progress notes.
Reportable incidents: If an incident occurred during the shift, you must include details of what happened and any witnesses.
Changes in client: Any noticeable changes concerning the client, including behavior, attitude, emotional temperament, and physical appearance.
Relevant events: Including visits from other healthcare providers, reactions to medication, interventions or assistance from others, and participation in general activities.
Guidelines to consider while making progress notes
To assist you in your process of writing the most effective progress notes possible, we have compiled a list of key considerations:
The Sooner, The Better: Write your progress notes immediately after the end of each shift. It might seem time-consuming, but it is the best way to ensure your information is accurate and you don’t forget anything.
Tailor To The Needs Of The Client: Remember that different clients will have different needs, so ensure your progress notes are relevant to the client. This could mean using different progress note templates for some clients.
Thorough, But Concise: These are the two most important aspects of a progress note. They need to include enough information so that others understand, but they shouldn’t be overly wordy or vague. Focus on using specific, understandable language.
Prioritize Objectivity Over Subjectivity: The information included in the progress note should be factual and backed up by evidence. Please don’t include your opinions or assumptions about the client or their behavior.
Accessible: Progress notes are often shared between people other than the person who wrote them, so they should be easy to understand and accessible. One way to ensure they are neat and easily accessible is by using online clinical documentation platforms to safely store your notes in a HIPAA-compliant manner.
Individualized plan in aged care progress notes example
Individualized plans are often created for individuals in aged care and are based on assessments, diagnoses, and treatments. They are tailored to meet each individual’s specific needs and establish achievable goals and treatment plans.
What is an individualized plan in aged care?
Individualized plans allow individuals to have the most excellent quality of life possible while maintaining their independence. The client is usually involved in creating and developing their individualized program, allowing them both autonomy and a sense of control over their future. Individualized plans in aged care typically include:
- Identification of potential future issues, including sickness, infection, and medication effects, and suggests steps to solve these issues.
- Activities to improve both cognitive and physical function. These could include socialization, puzzle games, and physical therapy.
- Any potential changes in medication that may be necessary and the effects these could have.
Importantly, individualized plans involve all healthcare providers, family members, and general support staff. This way, all spheres of the client’s life are accounted for, and everyone can be informed of the steps to take to ensure they receive the highest quality healthcare.
Create Better Progress Notes
Progress notes are a form of clinical documentation that necessarily tracks the progress and treatment of clients. Writing good progress notes can improve the quality of healthcare that the client is experiencing and protect you and your business. Hopefully, this article has provided you with a guideline on how to write the best notes possible and provide innovative clinical tools for your healthcare business!
Further Reading
.jpg)
