2. Industry terminology
2.1. Written communication
Progress notes are uses to record any intervention that you perform with a patient/resident. The standard format is SOAP (Subjective, Objective, Assessment, and Plan). This documentation must be completed at the time of the intervention.
While an incident report is incident focused, progress notes are resident/patient focused. For example, if you saw Mr O’Connell fall, you would follow the protocol for a fall. This incident would require immediate consultation with your supervising AHP and the completion of an incident report. You would also record a progress note about Mr O’Connell’s fall and the actions you took.
The AHP would be responsible for any updating of Mr O’Connell’s care plan, such as that he may need more support /closer supervision when walking.
Care plans are documents that address the consumer’s needs including:
- medical
- nursing
- mental
- psycho-social
- emotional
- spiritual
- physical.
Important
Don't forget how important it is to have good grammar in your written communications, and likewise the importance of speaking at the appropriate speed and pronunciation for verbal communication.
