What are progress notes in a medical record

Office notes are maintained as evidence of what we have done in a patient encounter, and they serve two general purposes: to remind us of the patient's clinical problems and treatment plans, and to help us communicate with colleagues about the care we have rendered.

The progress note is by no means the entire record of the visit. It is simply a snapshot of what transpired. For lack of time, many routine and normal findings are not recorded. In addition, because our job is to find the problem, not what is normal, we chart largely by exception. When we perform a physical on an established patient, it is a waste of time and chart space to record the family history for the fifth time or to go through the entire review of systems.

HCFA's bullet-counting system has twisted what should be a clinical document into an economic document, which physicians try to “fluff up” to achieve higher visit levels. The clinical effects of this are a loss of esteem for the writer of those notes and incredibly poor communication — but great documentation for the bean counters.

I agree that the 1997 “Documentation Guidelines for Evaluation and Management Services” are unnecessarily onerous for patient visits. That's why the CPT Editorial Panel has submitted a “new framework” to HCFA that would greatly simplify these guidelines. Like it or not, such guidelines are required to justify reimbursement for each visit.

I disagree, however, with the assertion that the medical record is not a reflection of the complete patient visit. In addition to being a clinical document, the medical record is also a legal document, and thus all pertinent positive and negative findings of the history and exam should be clearly documented. Remember: If it is not documented, it did not occur.

It's also important to remember that the documentation guidelines do not require the re-documentation of history and exam elements that have not changed; a reference to the previous recording of this information is adequate. And if you use the proper CPT code for preventive medicine visits, the documentation guidelines don't even apply!

While the current guidelines do need to be revised for easier clinical application, I believe that carefully applied guidelines can empower family physicians to code appropriately at higher levels of service for work we always do but usually do not record.

Progress notes are created by support workers at the end of a shift. This guide includes valuable tips on how to write progress notes to a high professional standard for the Disability and Home Care industry. Find out more.

Progress notes are a vital part of a care delivery framework and a must-have for any care delivery team.

They reflect a client's movement towards their goals, as identified in their Individual Support Plans, and also represent a record of events on each shift or visit, and thereby serve as a communication tool for staff.

By reading this guide, you can find out more about why progress notes are important, and what kind of information should be included in progress notes. You will also pick up valuable tips on how to write progress notes to a high professional standard.

Progress notes are documents created by support workers at the end of a shift and are an essential part of a Client Personal File. In progress notes, staff succinctly record details that document a client’s status and achievements. Progress notes are a tool for reflecting on a client’s movement towards their goals, as identified in their Individual Support Plans. They also represent a record of events on each shift or visit, and act as a communication tool for staff and families.

As well as being used in home care, progress notes may be used in community care, group programs, sheltered accommodation, and nursing homes.

Just like in home care, nursing progress notes are an essential record for improving the quality of care and support. They also function as a legal and medical record, and can be shared with both the patient or resident and their loved ones.

Nursing progress notes can be updated in real-time or completed at the end of the nurse’s shift. They should include details of a patient’s care, any changes in their condition or medication and any incidents.

In aged care, progress notes help ensure older people receive consistent, high-quality care. They are a legal record that details the care the client receives, their health and any important changes. Day to day, they allow carers to communicate in-team about the client’s condition.

Progress notes are particularly helpful when clients have memory loss, as they serve as a tool for communication between the client, their loved ones and carers. Family and friends can receive regular updates about the client’s activities. Moreover, the contents of the progress notes can be used to navigate conversations without making the client feel uncomfortable about forgetting things.

Progress notes are one of the most helpful tools in a carer’s or support worker’s arsenal. There are many reasons we write them, including:

1. Progress notes act as proof of service delivery

By recording progress notes, you can show clients, their loved ones and auditors that the promised services have been provided.

2. Progress notes are a legal record

Progress notes become part of a patient’s permanent legal record. They may be used in legal proceedings, audits and investigations. They also provide a paper trail in case of conflict or incidents, which brings us to our next point.

3. Progress notes can be used as evidence

Any incidents (whether proven or solely alleged) must be reported to the NDIS Commission, either directly or via a supervisor, manager, specified person, or member of the provider’s key personnel. You will probably also be asked to provide evidence of progress notes and/or a system for recording incidents during NDIS audits.

Reportable incidents and allegations include:

• Injury

• Alleged abuse and/or neglect by a worker, another participant, a family member, another service provider, visitors, members of the community, etc.

• Unlawful sexual or physical contact or assault.

• Sexual misconduct.

• Unauthorised use of a restrictive practice.

• Death

If you are unsure of whether to report an incident or allegation, report it! The relevant personnel will decide what (if any) action is needed.

For more information and guidance, you can refer to the NDIS Reportable Incidents Guide.

4. Progress notes help you prepare the client’s plan review

Progress notes link the services provided and the client’s progress to their overall plan, client goals and strategies. 

Information from progress notes can be used to write client NDIS progress reports, which usually need to be submitted every 12 months. These reports help the NDIS (or aged care decision-makers) with progress and care plan reviews. In turn, these then help guide the carers whose work it is to implement participant goals. 

Discover how to measure the outcomes on the NDIS website.

5. Progress notes are a tool for sharing information

Progress notes can be used to share information between carers, families and coordinators (including team leaders and managers). This allows all interested parties to stay abreast of changes in patient status, routines and needs.Progress notes can also act as handover notes for next shift staff. For in-home services, they play a vital role in ensuring transparency of care between care teams, as well as for primary carers.Here are some simple examples that demonstrate how sharing information recorded during care visits can be helpful:

Sharing information between different carers 

A carer working with a patient in the morning records in a progress note that the patient has not eaten their breakfast. The carer coming on shift with the same patient in the afternoon has access to that information and can make sure that the patient eats lunch.

Sharing information between care workers and families

A care worker goes out shopping with a patient with dementia and records the experience, including what was purchased. Having read the notes, the patient’s family can use the information as a point of conversation. 

Without context, it may be hard for a dementia patient to remember the morning visit to the shop, and it could frustrate them when the topic is raised. Reading the progress note, however, will enable a family member to ask detailed questions, such as: “How was shopping? I understand you bought new cushions, what colour are they?” This creates a more rewarding experience for both the patient and their family.

How to write Progress Notes

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 anydeviation 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.

Here are some important guidelines to consider when making progress notes:

• Progress notes should be recorded at the end of every shift.

• Progress notes can be written by hand or typed.

• Write down events in the order in which they happened.

• Include both positive and negative occurrences, and anything out of the ordinary.

• Record errors made by caregivers - even your own errors!.

• Keep in mind the goals in the client’s plan. You may wish to work from different progress notes templates for different patients.

• Write concisely, so that others can easily scan the information. At the same time;

• Notes need to include enough information that others can understand what happened.

• Where significant, state what occurred before, during and after and incident.

• Use plain language that any adult would be able to understand (even if they have no specialist knowledge, speak English as a second language, or have a learning disability).

• Consider using the STAR model to record information: Setting, Trigger, Action, Result.

• Be specific. For example: “At 3:45pm Jane’s temperature was 39 degrees”, not just, “Jane had a fever this afternoon”.

• Accurately describe the types of assistance given during each activity. Eg. Verbal cues, or hand-over-hand assistance.

• Write using the ‘active voice’ rather than ‘passive voice’. The active voice places the focus on the doer of the action:Active VoicePassive VoiceMr Ryan refused to eat breakfast.Breakfast was refused by Mr Ryan.Staff helped Mrs Bradford to get dressed.Mrs Bradford was helped to get dressed by the staff.Carer found Ms Smith on the bedroom floor.Ms Smith was found on the bedroom floor.The nurse changed Mrs Clair’s sheets.Mrs Clair’s sheets were changed by the nurse

• Information should be objective, not subjective. What did you see / hear / say / do? Record concrete, factual information. Do not include your opinions about the facts. (For more help with how to write progress notes objectively, see this NDS workbook

Here are examples of objective and subjective writing, taken from the same workbook:

Example of objective writing:

“At 3.30 pm Marcella returned from a walk to Albert Street Park and she was holding her right arm against her body. She had a graze and bruise on her right arm. Marcella said a dog had jumped on her when she was sitting on the grass at the park. She said she had been frightened and that her arm was sore.”

Example of subjective writing:

“Marcella must have bumped into something when she went on a walk to Albert Street Park, as she has grazed skin and a bruise on her arm. She was holding her arm and looked unhappy.”

How is ShiftCare revolutionising Progress Notes?

1. Recording and sharing on-going progress:

   ShiftCare’s Progress Notes provide a daily account of each client, their health and welfare and any developments in their care. This information can then be accessed by all carers and support-providers, and in turn, enable them to better meet the clients’ needs.

   What’s more, it’s easy for carers to record and share progress via the ShiftCare app. Speech-to-text technology allows carers to quickly record progress notes. The voice notes are automatically transformed into text ready to be submitted.

   

2. Smooth & Immediate Transfer of Handover Notes:

   Carers and support providers can access progress notes on their phone as soon as they’ve been submitted. This gives them an instant update on a client’s condition and any ongoing issues. Since it’s all digital, there’s no need to coordinate a handover of physical documents. Instead, sharing these notes between teams in real-time means no problem will be overlooked.

   

3. ShiftCare keeps records of progress notes for audit purposes:

   Auditors will inspect progress notes to check that carers have visited clients at the correct times and all concerns and incidents have been appropriately reported and handled.

   With the ShiftCare app, you’ll be well-prepared for an audit. All your progress notes and other important documentation will be available in one place. Records are stored securely on our server, and there is no risk of information loss, theft or damage.

   

Progress notes in disability, aged care and nursing aren’t just a legal requirement. They’re also a tool that will help your business run smoother by ensuring good communication between team members. Most importantly, progress notes enable you to provide high standards of care and monitor clients’ needs.

To discover how ShiftCare’s progress notes feature can revolutionise your business, sign up for a free trial.