ABSTRACT
Most facilities prefer the Subjective/Objective/Assessment/Plan method of charting in the Patient Oriented Medical Records, but the Data/Assessment/Plan method may be considered. Follow-up progress notes reflect changes in the following items: diagnosis, medical condition, allergies, diet, feeding, chewing and swallowing ability, dental status, skin condition, elimination function, mobility, and mental status. Appetite level, weight status, and new lab data or medications should also be reported. Prepare for care plan meetings in advance by gathering data and identifying problems or needs. Developing progress notes and corresponding care plan, think of one as a reporter answering the questions–who, what, when, and sometimes where and how. Reflect interventions as stated on the treatment or care plan. There is no substitute for meal rounds for gaining insight from clients before any documentation occurs.
