4 pts
3 pts
2 pts
1 pts
Every entry in the progress note must have at least one focus word or phrase at the beginning of the note. Choosing must be patient specific /client centered, describing pt need, change in pt condition, an acute condition or significant event in the patient's care.
subjective and/or objective information which supports the stated focus or describes observations, sign and symptoms, significant investigations and /or other assessments at the time of significant treatment.
Intervention(s) /action(s) performed by the caregiver on an analysis of the information gathered through observation, investigation and assessment.
A description of the patient's response to actions and interventions and/or the patient's progress toward goals; the impact of the intervention on the patient.
A description of the ongoing/resultant plan to manage the situation; this may be a change to the plan of care and will also need to be reflected in other care planning tools as appropriate.