Progress Note Standard
Progress notes need to explain what activity you did. Make sure to describe the following:
- What actions you took and what specific support you provided. Examples of supports that staff may document:
- Giving cues to help a person complete an activity, doing an activity because a person is unable to do so, monitoring to see if help is needed, offering encouragement and support, redirecting a person, taking care of personal items, supplies, or equipment, medication assistance, preparing food, guiding for street safety, using assistive devices, communication strategies, behavior supports, or safety plans
- Document if there are any new needs
Professional writing
•State the facts. Avoid personal opinions.
•Use respectful language.
•Avoid slang or abbreviations.
Progress Notes Examples
Example 1:
I helped Janea with hygiene before work. I re-brushed her teeth after she brushed them sinceshe has a hard time reaching the back teeth. I also adjusted the water temperature in theshower and assisted with washing her hair. I reminded her to use soap for washing her body. Ihelped her brush and style her hair appropriately for work. I provided reminders to pick outclean clothes for work and I tied Janea’s shoes.
Example 2:
I assisted Janea today with grocery shopping. I helped her at the store with selecting neededitems, staying within budget, counting correct change, communicating with the cashier andtransportation to and from the store. I reminded her to use her grocery-shopping list and helpedher fill out her checkbook ledger.
Reporting Incidents
If an incident occurs on shift, you must notify Best Care within 24 hours. The incident reportform can be found at https://bestcaremn.com/resource/incident-report-form/