Physical Therapy Programs - Sample operation improve Notes
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Writing action develop notes can be time enchanting but it is an foremost aspect of documentation. F-tag 248 clearly states that there must be a recipe in which each resident's program of activities is monitored. There are many ways to faultless develop notes. Below are two examples of a quarterly develop note.
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Mrs. X
Quarterly Review:
1/20/02
Since her admission on 10/9/01, Mrs. X has pursued an active relaxation 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 further reading materials and Mrs. X's favorite foods. Mrs. X is an active participant in daily recreational activities both on and off the unit including practice programs, adapted corporal games (bowling, basketball, ball games), word games, bingo, trivia, discussion, charm 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, however 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 compel in attending chapel services of all faiths. Mrs. X enjoys a range 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 favorite music, or find solace in the greenhouse if Mrs. X does not express interest in joining the group activity. Recreation staff will continue to invite Mrs. X to daily recreational activities and contribute 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 further sustain and companionship. See care plan whole 3 addressing mood and behavior, for definite interventions. Mary Sunshine, Adc action 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 uncomplicated 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 including Snoezelen, Five Alive, Sensory and Movement, Music Therapy and adapted reminiscing groups. R/t to poor cognitive status, Mrs. P requires broad assistance (i.e. Hand over hand, physical/verbal cueing) to share in relaxation programs. R/t contractures of both arms she is provided with U/E and L/E Prom during adapted corporal games and practice programs to allege corporal functioning. during sensory programs, a range 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 visual 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 contribute sensory stimulation to heighten responses to external stimuli and allege ability of life. See care plan whole 2 addressing contractures, for definite interventions. Mary Sunshine, Aac action Assistant
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