Progress Notes

1. Progress Notes KNR 279 Stumbo & Peterson, 2004

2. PROGRESS NOTES • Used to monitor progression toward or regression from the goals established in the treatment plan • If necessary, to modify the original plan of actions • Provide periodic updates to the original treatment plan

3. CONTENT • Progression, regression, no change towards goals • New patterns of behavior • Consistency of behavior • Verbal information provided by client or family • Successful or unsuccessful attempts at a task

4. CONTENT (cont.) • Appropriate or inappropriate interactions with staff, family, peers, visitors, others • Differences between behaviors in facility & community • Response to questions, requests, instruction • Self initiating behaviors, decision-making

5. CONTENT (cont.) • Attendance & participation • Physical cues • Environmental cues • Completion of assessment & where located

6. PRINCIPLES • Professional!!!!!!!!! • Accurate & timely • Behavioral language • Consistency • Brevity • Clarity • Correcting errors