Progress Notes Agencies may use different formats for progress notes Type of progress note may reflect various forms of chart organization
Source Oriented/Narrative Format Narrative progress note Does not have a specific structure Information can be organized in any logical manner Note must still reflect progress toward goals
Narrative Progress Note Example Client attended 33% of scheduled recreation therapy groups (sports 4/5/07, fitness 4/6/07). Concentration is improving as client was able to focus on task for 10 minutes. Will continue with current treatment plan and incorporate daily reminders to increase attendance at recreation therapy groups. Also see Stumbo & Peterson, 2004, p. 322
Problem-Oriented Medical Record: SOAP Progress Note S = subjective data Statements client makes about problem or course of treatment Could also be family or friend statements S: “I want to stay in my room. Leave me alone.” S: “I feel like I am making better decisions.”
SOAP O = objective data Gathered by observation of client’s actions or behaviors Must be stated in overt behavioral terms Does not include opinions Must only reflect behaviors that relate to the client’s problems or the initial treatment plan
SOAP O: Pt. asked questions about transportation to the activity, ticket prices, food, and return time. O: Pt. engaged in a 10 minute conversation with a peer and responded to questions about television shows.
SOAP A = analysis (or assessment) Based on S & O Can indicate progression, regression, or no change in patient’s condition related to problem A: Pt. has adequate social interaction abilities and can interact with peers for sustained periods of time.
SOAP P = plan Based on A Updates treatment plan Indicates additional information that may need to be collected Notes specific programs Notes intervention techniques Notes frequency and duration Notes when plan will be reevaluated Notes any new goals & objectives Indicates referrals to other services
SOAP P: Schedule two 1:1 sessions to reassess conversation skills. Enroll pt. in leisure planning group starting 4/11/07, MWF 10-11 am for 3 weeks. New objective: After 1 week in leisure planning group, patient will accurately complete a planning sheet for his community reentry outing as judged appropriate by CTRS. See Stumbo & Peterson, 2004, p. 324
SOAP(IER) I = intervention I: Stress Management, co-led with nursing E = evaluation Evaluates effectiveness of intervention Includes patient’s response to intervention Notes if goals or objectives were achieved E: Pt. did not meet exercise goal of 3 times a week due to complications from infection. R = revision to plan R: Move from intermediate to advanced leisure skills class.
Focus Charting: DAR(P) Progress Note Focus replaces problem from SOAP Current concern or behavior, e.g., aggressive social behavior, pre-op teaching Key word, e.g., activity tolerance Sign or symptom important to treatment plan, e.g., suicide threat, poor personal hygiene Acute change in condition, e.g., seizure, apathy Significant events, e.g., family visit, community reentry Could be problems or positive
DAR(P) D = data Subjective and/or objective information A = action Description of actions taken by RT in form of interventions or programs R = response Client’s response to interventions Goals/objectives attained Client outcomes P = plan Next interventions See Stumbo & Peterson, 2004, p. 326
DAR(P) Example Focus: Hallucinations D: Mumbling to self during RT program on 4/23 and 4/24, pacing, unable to focus on task. A: Provided verbal cues to remain focused. R: Able to focus for 10 minutes with support but becomes agitated beyond 10 minutes. P: Continue involvement in RT program to facilitate focusing on external stimuli. Gradually increase time requirements. Provide positive verbal comments for sustained attention.
Charting By Exception Used when standardized clinical pathways (protocols) for a diagnostic category are used Charting only occurs for exception to plan or outcome not achieved or outcome achieved earlier than anticipated Must include date, what intended outcome was, explanation of why variance occurred, and plan to deal with variance May be flow sheets
PIE Progress Notes P = problem P: Sporadic attendance in assigned groups, mumbling & telling CTRS to leave him alone. I = intervention Staff’s response to problems I: Spoke with client about behavior and will set firm limits for hostile behaviors. E = evaluation Staff’s evaluation of how effective intervention was and future plans E: Client responded to firm limits, apologizing for behavior. Will establish daily contact to facilitate rapport with CTRS.
DAIR Progress Note DA = data/assessment Subjective or objective information I = intervention What was done for the patient R = response Patient’s response to intervention or interaction
DAIR Example D: 80 y/o white male pacing in hallway. Pulling at door handle. Fretful. Grabbing at staff. A: Pt agitated. Denies pain. I: Reality orientation, redirection, diversion and comfort offered. Monitor for escalation. Decrease stimuli. R: Cooperative. Redirects easily. Agreed to meet with CTRS in quiet alcove.
BIO Progress Note B = behavior Notable behavior related to reason for admission and is on treatment plan Change in functioning I = intervention Staff interventions, including what was said, done, and location O = outcome Patient response to intervention, including verbal and physical response Patient response to education including indication of understanding or skill demonstration
Other Progress Notes There are also other forms of notes Many are formulas Some are combinations