2 Progress Notes Agencies may use different formats for progress notes Type of progress note may reflect various forms of chart organization
3 Source Oriented/Narrative Format Narrative progress noteDoes not have a specific structureInformation can be organized in any logical mannerNote must still reflect progress toward goals
4 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
5 Problem-Oriented Medical Record: SOAP Progress Note S = subjective dataStatements client makes about problem or course of treatmentCould also be family or friend statementsS: “I want to stay in my room. Leave me alone.”S: “I feel like I am making better decisions.”
6 SOAPO = objective dataGathered by observation of client’s actions or behaviorsMust be stated in overt behavioral termsDoes not include opinionsMust only reflect behaviors that relate to the client’s problems or the initial treatment plan
7 SOAPO: 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.
8 SOAP A = analysis (or assessment) Based on S & O Can indicate progression, regression, or no change in patient’s condition related to problemA: Pt. has adequate social interaction abilities and can interact with peers for sustained periods of time.
9 SOAP P = plan Based on A Updates treatment plan Indicates additional information that may need to be collectedNotes specific programsNotes intervention techniquesNotes frequency and durationNotes when plan will be reevaluatedNotes any new goals & objectivesIndicates referrals to other services
10 SOAP P: Schedule two 1:1 sessions to reassess conversation skills. Enroll pt. in leisure planning group starting 4/11/07, MWF 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
11 SOAP(IER) I = intervention E = evaluation R = revision to plan I: Stress Management, co-led with nursingE = evaluationEvaluates effectiveness of interventionIncludes patient’s response to interventionNotes if goals or objectives were achievedE: Pt. did not meet exercise goal of 3 times a week due to complications from infection.R = revision to planR: Move from intermediate to advanced leisure skills class.
12 Focus Charting: DAR(P) Progress Note Focus replaces problem from SOAPCurrent concern or behavior, e.g., aggressive social behavior, pre-op teachingKey word, e.g., activity toleranceSign or symptom important to treatment plan, e.g., suicide threat, poor personal hygieneAcute change in condition, e.g., seizure, apathySignificant events, e.g., family visit, community reentryCould be problems or positive
13 DAR(P) D = data A = action R = response P = plan Subjective and/or objective informationA = actionDescription of actions taken by RT in form of interventions or programsR = responseClient’s response to interventionsGoals/objectives attainedClient outcomesP = planNext interventionsSee Stumbo & Peterson, 2004, p. 326
14 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.
15 Charting By ExceptionUsed when standardized clinical pathways (protocols) for a diagnostic category are usedCharting only occurs for exception to plan or outcome not achieved or outcome achieved earlier than anticipatedMust include date, what intended outcome was, explanation of why variance occurred, and plan to deal with varianceMay be flow sheets
16 PIE Progress Notes P = problem I = intervention E = evaluation P: Sporadic attendance in assigned groups, mumbling & telling CTRS to leave him alone.I = interventionStaff’s response to problemsI: Spoke with client about behavior and will set firm limits for hostile behaviors.E = evaluationStaff’s evaluation of how effective intervention was and future plansE: Client responded to firm limits, apologizing for behavior. Will establish daily contact to facilitate rapport with CTRS.
17 DAIR Progress Note DA = data/assessment I = intervention R = response Subjective or objective informationI = interventionWhat was done for the patientR = responsePatient’s response to intervention or interaction
18 DAIR ExampleD: 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.
19 BIO Progress Note B = behavior I = intervention O = outcome Notable behavior related to reason for admission and is on treatment planChange in functioningI = interventionStaff interventions, including what was said, done, and locationO = outcomePatient response to intervention, including verbal and physical responsePatient response to education including indication of understanding or skill demonstration
20 Other Progress Notes There are also other forms of notes Many are formulasSome are combinations