Presentation on theme: "HPR 451. What is significant??? Progress toward attainment of client goal Regression from attainment for client goal New pattern of behavior "— Presentation transcript:
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
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.
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?
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.
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)
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)
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.
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
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
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.
Each agency will have forms and procedures – Risk Management 1. client injury or death 2. broken equipment (van lift) 3. client elopement 4. medication error 5. child abduction 6. patient falls
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?
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