Skilled Nursing Facilities

Creating a Structured Progress Note

A Structured Progress Note (SPN) can be added to an assessment in the Custom Assessments Library. An SPN allows you to build the content of a Progress Note that pushes to the Prog Note tab of a resident's chart upon completion of the assessment. Content for a SPN can populate from multiple areas, including responses, narrative responses, resident profile, scores, and scoring categories.

Several items must be considered/completed before creating a Structured Progress Note:

  • Assessment - The structure of the assessment must be completed in the Under Construction section. This includes adding sections (if applicable), question groups, questions, and narratives (if applicable - see below).

  • Narratives - Narrative responses are optional, however if you are using them they must be added while the assessment is in the Under Construction section. They cannot be added after the assessment is moved to Ready for Scoring/SPN Setup and the SPN is created.

    Creating Narrative Responses

  • Progress Note Type - A new Progress Note Type must be created for the Structured Progress Note. Use a description the same as, or similar to, the assessment name.

    Creating a New Progress Note Type

  • Ready for Scoring/SPN Setup - The assessment must be moved from the Under Construction section to the Ready for Scoring/SPN Setup section, using the make available for scoring link.

  • Scoring/Scoring Categories - Scoring and scoring categories are optional for a Structured Progress Note, and optional for an assessment in general. If you want to pull scoring or scoring categories results into the Structured Progress Note, they must be completed after the assessment is moved to Ready for Scoring/SPN Setup.

    Adding Scoring to An Assessment

    Adding Assessment Scoring Categories

  2. Click the assessment name.

  3. Click create template.

  4. Progress Note Type - select the PN Type that you created for this assessment.

  5. In the Note Text field, build your SPN by entering text, selecting any of the below options, and clicking Insert.

    For example: select First Name > click Insert > enter a space > select Last Name > click Insert > enter a space > enter "was admitted on" > enter a space > select Date of Admission > click Insert > enter a period.

    • Resident's score for selected formula - select a score to pull into the SPN, if applicable. If no assessment scores were created, this field is grayed out.

    • Resident's category for selected formula - select a category to pull into the SPN, if applicable. If no assessment scoring categories were created, this field is grayed out.

    • Question Response - select a response from the assessment to pull into the SPN. Use the Assessment Form quick link to determine section, question group, and question number.

    • Alternate Narrative Response - select a narrative response to pull into the SPN, if applicable. Use the Narrative Descriptions quick link to review available narrative responses. If no narratives were created, this field is unavailable.

    • Selected response(s) within a question group - if there is a question group in the assessment that only contains questions with multi-select check boxes, the question(s) are available to select. In the SPN the response(s) appear separated by commas.

    • Resident Profile Information - select information to pull into the SPN from the resident's profile, e.g. First Name, Last Name, Date of Admission.

  • Use the quick links to assist you as you build your Structured Progress Note:

    • Assessment Form - Generate a printable view of the assessment.

    • Narrative Descriptions - Generate a printable view of any narrative responses created and available for this SPN.

    • Preview - View the SPN (save before you preview).

  • Make sure your cursor is in the correct spot in the Note Text field before selecting an item and clicking Insert.

  • Save your work often, especially if it is a long SPN.