The Memory Unit OT

Within the skilled nursing setting, progress notes are required every 10 sessions in order to provide routine assessment of the patient’s progress to date.

Within a progress note, we review and update goals, re-administer standardized assessments, and summarize the overall impact of therapy services on the patient within the last 2 weeks. Then, we provide a statement of justification for continued services. In other words, we state why this individual requires further therapeutic intervention.

Some companies and facilities will allow COTAs to complete progress notes, others mandate that progress notes are only completed by the OTR. Most of the companies I’ve worked for mandate that the progress note is completed during the session, with the patient present.

Typically there is room within a progress note template to document a patient’s subjective comments about the care they have received and what they’re looking to get out of future treatment sessions.

So how does this translate to memory care?

I mean, we’ve been talking about how it’s difficult enough to attend to a daily note within a session, especially when our patients require 100% supervision and supports. But what about a progress note, a recertification, or a discharge summary?

I would say that similar rules apply. The recommendations that I would make for bulky documentation are close to if not the same as what I recommended for daily documentation. That being said, there are a few strategies that I might use if I now an individual can attend to something for at lest a few minutes.

I’ll try to do the progress note while the patient is engaged in some sort of structured community task.

This could be a restorative dining program, a music or craft activity, or an outdoor group. If I know that the individual can attend to this sort of task for long enough, I will ensure that they are engaged in the activity, sit close by to cue and redirect as needed, then complete the progress note during the session.

I’ll try to do the progress note while the patient is with a primary caregiver or family member.

If the patient is present and engaged with a family member or care partner, you’ve got an extra set of hands to help provide appropriate supports to the patient, AND you’ve got someone to touch base with regarding therapy progress.

I’ll try my best to get as much of the progress note done during the session as possible.

The reality is, we may not always be able to document 100% of our notes during our sessions. Sometimes you’ve just gotta take a little time at the end of the day to get the notes done. But to give myself at least a little head start, I like to jot down notes during the actual session. I’ve got a freebie for you to help organize these notes into a quick, single page. Just before the session, I’ll jot down the goals I need to update, and any standardized tests I need to re-administer (with the previous scores if I have time to look that up). Then, during the session, I’ll take notes based on my own observations as well as input from other staff and therapists. These notes will focus primarily on what’s better and what’s worse since the last assessment.