A progress note is written information that describes what you did to meet the needs of the person you serve. You must document your DSP activities in progress notes.

NEW: The State has notified us DSP's are required to write daily notes, this will be mandatory.

This toolkit is aimed at guiding Direct Support Professionals (DSPs) in creating effective, detailed, and meaningful progress notes, ensuring consistent, high-quality care aligned with the individual's goals and needs.

1. What to Include in Progress Notes:

• Specific Actions and Support: Detail the actions taken and the support provided. Include how you assisted with daily activities, managed medication, prepared food, ensured safety, and used communication strategies or assistive devices.
• Health and Safety Needs: Describe how you addressed the individual's health and safety needs, including any adjustments made to the care plan.
• Progress Toward ISP Goals: Document any progress or challenges related to the individual's ISP goals and outcomes.
• Plan Effectiveness and New Needs: Reflect on the effectiveness of the current plan and identify any new needs or adjustments required.

2. Activity and Support Examples:

• Home and Community Activities: Include assistance with eating, drinking, dressing, grooming, bathing, hygiene, mobility, bathroom support, and household chores like housekeeping and laundry.
• Engagement and Monitoring: Describe how you engaged the individual in activities, monitored their needs, offered encouragement, and managed their personal items or equipment.

3. Privacy and Security in Progress Notes:

• Confidentiality: Avoid including names of other individuals served and ensure secure submission of progress notes.
• Incident Reporting: Document and report any unusual incidents, injuries, accidents, acts of aggression, or any other significant events as per the guidelines.

4. Professional Writing in Progress Notes:

• Clear and Factual: State the facts clearly, avoiding personal opinions, slang, or abbreviations.
• Timeliness and Accuracy: Write notes soon after the service to ensure accuracy and submit them when you are about to leave your shift to keep the team updated.

5. Resource for DSP:

• Person-Centered Language and Practices: Access eLearning modules and community resources to enhance your skills in person-centered practices.
• Incident and Abuse Reporting: Familiarize yourself with the incident reporting requirements and mandatory abuse reporting guidelines.
• Confidentiality and Training: Utilize resources offered by the Oregon Home Care Commission and other organizations for confidentiality practices and professional development.

 

Strengthening Progress Notes Examples:

Unacceptable vs. Satisfactory: Compare examples of insufficient progress notes with satisfactory ones, highlighting the importance of detail, specificity, and relevance in documenting support activities.

Example 1 - Mealtime Support

Unacceptable: Assisted with eating.

Satisfactory: Supported John during lunchtime. Encouraged self-feeding with adapted utensils for improved dexterity. John successfully ate 75% of his meal independently and expressed satisfaction. Monitored for choking hazards and ensured a calm, focused meal environment.

Example 2 - Community Engagement

Unacceptable: Accompanied to the park.

Satisfactory: Supported Lisa's participation in a community event at the local park. Assisted with social interactions, introducing her to three new community members. Lisa communicated using her AAC device and shared her artworkwith peers. Facilitated a safe, inclusive environment and observed a noticeable increase in Lisa's confidence in social settings.

Example 3 - Personal Hygiene

Unacceptable: Helped with morning routine.

Satisfactory: Assisted Mark with his morning hygiene routine. Provided step-by-step guidance for toothbrushing, ensuring all teeth were thoroughly cleaned. Supported safe showering, ensuring non-slip mats were in place and the water temperature was appropriate. Mark completed the routine with minimal verbal prompts, showing progress in his independence.

 

Example 4 - Mobility and Physical Activity Support

Unacceptable: Went for a walk.

Satisfactory: Assisted Sarah with a 30-minute outdoor walk, focusing on enhancing her mobility and endurance. Supported her use of the walker, ensuring safe navigation of uneven surfaces. Sarah completed the walk with two brief rests, showing improved stamina compared to previous sessions. Encouraged hydration and monitored for signs of fatigue throughout the activity.

Example 5 - Behavioral Support

Unacceptable: Managed behavior.

Satisfactory: Implemented behavioral support strategies during a challenging situation with Alex at the community center. Used calm, clear communication and redirection techniques to address his frustration. Alex responded positively to the interventions, de-escalated within 10 minutes, and resumed participation in the group activity. Documented the incident and the effectiveness of the strategies used.

Example 6 - Skill Development

Unacceptable: Worked on life skills.

Satisfactory: Conducted a life skills session with Emma, focusing on budgeting and money management. Used real-life scenarios to practice identifying costs, making changes, and budgeting for weekly expenses. Emma demonstrated a 20% improvement in her ability to calculate total costs and manage her budget independently. Reinforced learning through positive feedback and planned follow-up sessions.

Example 7 - Medication Assistance

Unacceptable: Gave medication.

Satisfactory: Assisted Noah with his medication by reminding him of the scheduled time as per the medication administration record (MAR). Ensured Noah self-administered the correct dose of medication. Monitored Noah for 30 minutes post-administration for any adverse reactions. Documented the assistance provided, Noah's self-administration, and any observations accurately, ensuring adherence to healthcare guidelines and individual care plans.

Example 8 - Medication Administration

Unacceptable: Gave medication.

Satisfactory: Administered prescribed medication to John at the scheduled time, following the physician's instructions and the (MARS) guidelines. Ensured that John took the correct dosage of his blood pressure medication, monitoring him for 30 minutes post-administration for any adverse reactions. Documented the time, dosage, and John's response in his medical record, noting his stable condition and compliance with the medication regimen.

Example 9 - Wound Care and Cream Application

Unacceptable: Applied cream.

Satisfactory: Conducted wound care for Maria, meticulously cleaning and inspecting her surgical wound before applying the prescribed antibiotic cream. Utilized sterile techniques to prevent infection and promote healing. Maria reported a decrease in pain and discomfort during the procedure. Documented the wound's appearance, the type and amount of cream applied, and Maria's response to the treatment in her care plan, ensuring continuity of care and monitoring for signs of improvement or complications.

Example 10 - Sensory Support

Unacceptable: Addressed sensory needs.

Satisfactory: Provided sensory support to Max during high-stimulus situations at the day program. Utilized sensory tools such as weighted blankets and noise-canceling headphones to help him manage sensory overload. Observed a reduction in signs of distress, and Max engaged in activities for longer durations without sensory-related disruptions.

Example 11 - Communication Enhancement

Unacceptable: Practiced communication.

Satisfactory: Engaged in a targeted communication session with Ava using her speech-generating device. Focused on expressing basic needs and preferences. Ava successfully navigated her device to communicate her choice of activities for the day and responded to questions with 80% accuracy. Celebrated her progress and planned to introduce more complex phrases in future sessions.

Conclusion

Remember, progress notes are not just a formality but a vital part of the care process. They inform care strategies, ensure compliance, and most importantly, they tell the story of the individual's journey towards their goals. By adhering to these guidelines and utilizing the available resources, DSPs can ensure their documentation is impactful, respectful, and person-centered.