Client Progress Notes Guidelines. All progress notes should include a succinct summary on the following:

Transcription

1 Client Prgress Ntes Guidelines Purpse Prgress ntes are an essential part f a Client Persnal File where staff and clients succinctly recrd details t dcument the client s status r achievements whilst a client f RFNSW. Prgress ntes are a tl fr reflecting n a client s mvement twards their gals as identified in their Individual Supprt Plans and als represent a recrd f events n each shift r visit, a cmmunicatin tl fr staff. It is essential that prgress ntes reflect the strengths and recvery-fcused elements f RFNSW s wrk with clients, t enable the stry f their jurney thrugh the prgram t emerge. All prgress ntes shuld include a succinct summary n the fllwing: A client s prgress twards gals identified in Individual Supprt Plans (actins taken, prgress made, barriers identified). Level f supprt prvided by staff (i.e. increasing r decreasing, verbal prmpts r physical supprt, staff cmpleting tasks fr client). The client s level f participatin in and partnership with the RFNSW service. The clients significant achievements and changes. RFNSW Client Prgress Ntes Guideline March * This pint will be bslete within CIMS

2 Appintments attended The utcme f Service Crdinatin Meetings. All cmmunicatin with ther services invlved with client (including phne calls, s, faxes, face-t-face cntact). All attempts t cntact ther services need t be recrded. Referrals made. Grup activity participatin (prvided by the RFNSW service and externally). Any infrmatin given t clients Any fllw-up required. All infrmed cnsent decisins (e.g. Client prvided cnsent fr staff t discuss lw md with mental health case manager). Imprtant Pints Regarding Prgress Ntes Persnal client file ntes including prgress ntes are legal dcuments. Prgress ntes can als be subpenaed at any time and staff can be crss-examined in a curt regarding the cntents f prgress ntes. Remember all client data in the persnal client file including prgress ntes is t be kept cnfidential. All client persnal files must be kept in a secure lcatin and accessed nly by authrised RFNSW staff. Ensure all sectins f the file, are kept in a clean and tidy cnditin in the apprved RFNSW rder. Prgress ntes must be kept in a chrnlgical rder.* RFNSW Client Prgress Ntes Guideline March * This pint will be bslete within CIMS

3 An entry int the prgress ntes must be recrded during every cntact r each shift (mrning, evening and night) depending n the prgram. Fr residential services: fllwing night shift, where there has been n cntact, a prgress nte must be made stating Nthing t Reprt n Night Shift. All prgress ntes shuld be read at the start f each shift, in rder that supprt wrkers have a clear indicatin f the client s current situatin, what supprt the client will require, r what fllw-up activities need t ccur during the shift. All prgress ntes shuld be written with reference t the previus entry. Fr example if mrning shift ntes refer t client s lw md, the subsequent ntes n evening shift must cmment n md (i.e. imprvements, nging cncerns, management f cncerns). Prgress ntes must reflect the client s cmmunicatin, behaviur accurately and fairly. When writing prgress ntes wrkers must be mindful f hw smene reading the ntes will perceive the entries regarding the client and the RFNSW service prvisin. Client s have the right t request t read their wn file ntes. D s and Dn ts f Writing Prgress Ntes D Write the Client s full name n each page.* RFNSW Client Prgress Ntes Guideline March * This pint will be bslete within CIMS

4 Recrd date and time f every new entry in the date clumn. Time shuld be in 24 hur time (i.e fr 11pm).* Make entries as clse t the time f client cntact as pssible. (Cntempraneus) Identify late entries as such. Recrd the date and time that the late entry is being made in the date clumn, and the date f the cntact in the ntes sectin (i.e. written in retrspect fr 13/02/2011). Cntinue ntes by clearly stating n the new page: i.e. 13/02/2011 (cnt) in the date clumn n the fllwing page.* Write entries in black bir pen (nt felt tip pens).* Write legibly. Print if yur handwriting is nt legible.* Ensure that the spelling, grammar and punctuatin is crrect.* Use apprved abbreviatins nly. Write cncisely. Stick t essential infrmatin. Ntes can be written using headings and dt pints t assist with brevity. Recrd the names f peple invlved in cnversatins, activities r incidents. Use Actin plans t enhance cmmunicatin and reduce the risk f fllw-up being lst in verbal handver. Examples f sub-headings that can be used include: Actin Plan: fr any tasks t be fllwed up n as numbered items eg. Phne Call t be made t... Discussin regarding t take place... Supprt t appintment.... RFNSW Client Prgress Ntes Guideline March * This pint will be bslete within CIMS

5 Outcme: Phne call t talked abut 2.Discussin had re: the fllwing: a). Jane s achievements thrugh the week... b). Jane s nging lw md... 3) Observatins f.... Make reference t related ntes written in previusly. Fr example, (see entry n 3/2/11) yu may cmment n the client s md (bservatins/discussin re: md, supprt prvided, hw client managed). Use descriptins: bjective (when staff reprt n things that they bserve) r subjective (when staff reprt n what the client says r feels). Observatins are reasnably undisputable facts f actin, appearance r statement. Write yur bservatins as yu saw them in a factual manner (e.g. Jane was bserved t be crying, head in hands). Be descriptive in yur ntes, describe what was actually said, tne used, bdy language etc, i.e. Mary was shuting ludly in a high pitched angry way, swearing and saying I was useless. Thrughut her shuting she was staring wide eyed and pinting at me. Be mindful f language used. Cmment in a respectful and nn-judgemental manner, using strengths and recvery-fcused language. Sign the prgress nte after each entry, The wrker making the entry must prvide their signature, designatin and printed name [i.e. Samantha Jnes (S Jnes MHRW).* Dn t Alter ntes r use crrectin fluid. Incrrect entries shuld be crrected by drawing a single straight line thrugh the mistake and writing errr and initialling abve the errr. The crrect wrd r statement shuld then fllw.* RFNSW Client Prgress Ntes Guideline March * This pint will be bslete within CIMS

6 I.e. Jan stated that she had taken medicatin errr JF did nt take her medicatin tday. Leave any spaces between entries. Use a line t fill in the blank area.* Transcribe dses f medicatin in prgress ntes (As per RFNSW plicy) i.e. d nt write the milligrams next t the medicatin name, write instead name f staff bserved 1 ½ tablets f Lithium taken ). Write a diagnsis if yu are nt qualified t make a diagnsis. I.e. Jane s is suffering with anxiety. Write symptms instead (e.g. Jane displays symptms r signs cnsistent with anxiety, wringing hands, sweating, Jan reprts lss f appetite,... Use the fllwing wrds: abnrmal, abusive, anxius, impulsive, irratinal, verwhelmed, resistant, suicidal, threatened, trubled, delusinal, dangerus, disturbed, hysterical, immature, uncperative, lazy, unfit, stubbrn etc. UNLESS they are accmpanied with a clarificatin. I.e. I bserved Jane t be highly anxius, biting nails, pacing arund the rm, pulling at hair, saying that she felt like her head wuld explde re: subjective feelings f anxiety. Use jargn. Ensure yu understand and can clarify all language used (i.e. d nt use clinical terminlgy unless yu are cnfident f the meaning and can explain the meaning). Make assumptins. D nt use the wrd appeared. Express yur pinins r impressins UNLESS yu state that it is yur pinin. include infrmatin such as I said then she said and I went t their hme at 8.30am but nne was up s I went back t the ffice and will return t check in at the hme in 40 mins RFNSW Client Prgress Ntes Guideline March * This pint will be bslete within CIMS