A progress note is by no means the entire record of the visit. It is simply a snapshot of what transpired, including the most significant factual information. If the carer is already familiar with the client’s routines and behaviour, the main point is to note any deviation from the client’s normal routines and patterns.
Progress notes are partly generic in nature; for example, comments on a patient’s physical state and emotional wellbeing are likely to be appropriate whether the setting is mental health care, disability care, dementia care, or any kind of nursing context. Beyond this, progress notes should also relate to a client’s individual plan; to their individual goals and strategies.
All progress notes must include:
Your name. The date and time. Details of any reportable incidents or alleged incidents, including those involving peers or others, and including details of witnesses if there are any. Other types of information that it may be appropriate to record in progress notes, depending on the specific home care situation, include:
Visits from health professionals. Changes emotional wellbeings. Carer interventions and assistance given. Changes in behaviour. Degree of participation in activities. Behaviour of concern (what happened before, during and after). Reactions to medications. Concerning changes in physical appearance. Dietary notes.