TYPES OF PROGRESS/SERVICE NOTES
Narrative Charting
EXAMPLE:
Recreation Therapy Note 4/28/2001
Client Attended 33% of scheduled recreation therapy intervention groups (sports 4/23/2001, crafts 4/24/2001). Concentration is improving as client is able to focus on task for 10 minutes during both groups. Auditory hallucinations continue to be a problem as client reports reason for nonattendance at other intervention groups—“ My voices told me not to come.” During verbal exchanges, some hostility displayed with peers and staff (e.g., told staff “Leave me alone!”) but physical aggressiveness was not present. Client did request to use the heavy bag 5 times this past week when feeling agitated. Will continue with current intervention plan and incorporate daily reminders to increase attendance at intervention groups.
Signature, CTRS
SOAP Charting
EXAMPLE:
Recreation Therapy Note 4/28/2001
S: “When I come to recreation, I don’t hear the voices as much.”
O: Attended 2 of 6 scheduled intervention groups ( i.e., sport group 4/23/2001, and crafts 4/24/2001). Pacing, able to focus for 10 minutes during craft and sport groups. Hostile with staff telling them to leave him alone. No hostile behaviors with peers, muttering to self most of the time during activities. Requested heavy bag 5x during the week.
A: Client continues to respond to auditory hallucinations, has difficulty with concentration and with interactions with staff and peers. Some progress made with controlling aggressive outbursts and task attention. More comfortable with social groups.
P: Continue with TR intervention plan, begin daily 1:1 sessions for 15 minutes to facilitate trust relationship, review activity schedule each AM following morning meeting to facilitate attendance. Provide firm limits for aggressive outbursts, praise self-initiated use of the heavy bag for self-control, and review behavioral contract for attending intervention groups.
Signature, CTRS
PIE Charting
EXAMPLE:
4/28/2001 Recreation Therapy Note
P: Attendance at groups sporadic (attended 2 of 6 intervention groups: sports 4/23, crafts 4/24), mumbling during groups, and hostile with staff telling them to leave him alone.
I: Spoke with client about consistent attendance, utilized refocusing techniques when client was mumbling, and set firm limits for hostile behavior.
E: Client responded to firm limits, apologizing for bx and requesting use of heavy bag. With cues, client can focus for 10 minutes on task. Client agrees that he needs reminders to attend intervention groups due to confusion created by auditory hallucinations therefore will establish daily contact to facilitate trust and increase attendance at intervention groups.
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