Writing performance improve notes can be time moving but it is an prominent aspect of documentation. F-tag 248 clearly states that there must be a formula in which each resident's program of activities is monitored. There are many ways to faultless improve notes. Below are two examples of a regular improve note.
Mrs. X
Quarterly Review:
Music Teacher Supplies
1/20/02
Since her admission on 10/9/01, Mrs. X has pursued an active free time lifestyle. She is alert and oriented to all realms and makes her needs known. She is sociable with both staff and peers and initiates conversations. Her family members are very supportive and visit weekly, providing additional reading materials and Mrs. X's beloved foods. Mrs. X is an active participant in daily recreational activities both on and off the unit along with exercise programs, adapted bodily games (bowling, basketball, ball games), word games, bingo, trivia, discussion, beauty groups, music programs, cooking and crafts. Mrs. X also joined the Resident Council and has attended 1x this quarter. She has been invited to attend the Young Adult Group, any way has declined. She enjoys going to the greenhouse for horticultural therapy sessions and the off unit special events. Although a practicing Roman Catholic, Mrs. X states she finds much power in attending chapel services of all faiths. Mrs. X enjoys a variety of independent activities including: talking on the phone in her room, listening to music on her Walkman (country and 50-80's music), reading large print books, crossword puzzles and watching movies in her room. Recreation Staff provides movies, crossword puzzles and large print reading materials. Mrs. X has episodes of tearfulness and often dwells on her illness. Recreation staff encourages her to pray, listen to beloved music, or find solace in the greenhouse if Mrs. X does not express interest in joining the group activity. Recreation staff will continue to ask Mrs. X to daily recreational activities and furnish supplies for independent pursuits. In addition, Mrs. X will be encouraged to attend the Young Adult Group to spend time with residents of her age group for additional withhold and companionship. See care plan whole 3 addressing mood and behavior, for exact interventions. Mary Sunshine, Adc performance Director
Mrs. P
Quarterly Review:
9/8/02
Mrs. P remains alert with obscuring and forgetfulness. She is oriented to self and her speech is limited. She responds to easy direct questions by nodding her head or mumbling. Mrs. P is Oob daily in a recliner chair and spends much of the day in the dayroom where she is engaged in recreational activities along with Snoezelen, Five Alive, Sensory and Movement, Music Therapy and adapted reminiscing groups. R/t to poor cognitive status, Mrs. P requires overall aid (i.e. Hand over hand, physical/verbal cueing) to partake in free time programs. R/t contractures of both arms she is provided with U/E and L/E Prom during adapted bodily games and exercise programs to speak bodily functioning. during sensory programs, a variety of Recreational techniques are utilized to elicit responses to stimuli including: Aromatherapy for olfactory stimulation; hand massages, textured objects and props (yarn) for tactile stimulation; pictures of interest (cats) fiber optic lights and bubble towers for optical stimulation; ice cream, pudding, flavored lip balms etc. For gustatory stimulation; and music (Italian and singalong) as well as nature sounds, for auditory stimulation. Mrs. P responds to sensory stimulation by tracking objects, vocalizing, smiling, laughing, humming, and tapping feet and hands. She especially enjoys Italian music and the song "O Solo Mio". She also participates in argument and reminiscence groups when asked closed-ended questions. Recreation staff provides one to one sensory programs Prn. family visits are irregular. Recreation staff will continue to furnish sensory stimulation to enhance responses to external stimuli and speak capability of life. See care plan whole 2 addressing contractures, for exact interventions. Mary Sunshine, Aac performance Assistant
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Sample performance enlarge Notes
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