Skilled Nursing Facilities

Creating Progress Notes

You can create progress notes to record care-related notations in a resident's legal chart to document care and treatment progress.

You can create different progress note types. For example infection, order, behavior, and communication notes. All notes created in the application appear in the Progress Notes tab of the resident's chart. Based on the type of progress note selected, you might enter your note in a single area or enter your note based on prompts to document the care or issue. There is no limit to the length of your progress note.

You can strikeout a progress note when documentation is completed in error or for instances when you want to remove a progress note from the resident chart. Only the author can strikeout the note.

You can also link a progress note to another progress note or link it to a Care Plan. 

Note

You can edit the date and time to reflect your documentation needs. If the effective date and time is in the past, it may automatically be identified as a Late Entry, depending on your configuration settings.

  1. Clinical >Resident > Prog Notes.

  4. scr_sl_infection_progress_note.jpg

  • Type - Select option.

  • This note is a follow up to - Search and select to link this progress note to another note.

  • Care Plan Item or Task - Search and select to link this progress note to a Care Plan item or task.

  • Effective Date and Time - Date and time shows as current, but can be changed. The date and time cannot be in the future.

  • Select the appropriate options to: 

    • Show on Shift Report - Select option.

    • Show on 24 hour Report - Select option.

    • Show on MD/Nursing Communications Report - Select to show.

    • Edit Care Plans Immediately - Select to navigate to the Care Plan when you complete your progress note.