Why do we write progress notes? The purpose of writing progress notes is: List 4 reasons Who reads the progress notes? The progress notes will be read and used by: List 3 possibilities What is done with the information in progress notes? How is the information used? What actions are taken based on the information? The information in progress notes is used to: List 4 options What information needs to be reported in progress notes? The information we need to include in progress is: List 5 possibilities Definitions Objective writing Objective writing is based on facts and observations. It is a description of what actually happened. Ask yourself what did you: Hear? Say? See? Do? Objective writing is not influenced by personal feelings or opinions. Example of objective writing At 3.30 pm Marcella returned from a walk to Albert Street Park and she was holding her right arm against her body. I noticed that she had a graze and bruise on her right arm. Marcella said a dog had jumped on her when she was sitting on the grass at the park. She said she had been frightened and that her arm was sore. Subjective writing Subjective writing is based on or influenced by the writer’s point of view, emotions, assumptions, speculation, judgement or interpretations. We are often subjective. Example subjective writing Marcella must have bumped into something when she went on a walk to Albert Street Park, as she has grazed skin and a bruise on her arm. She was holding her arm and looked unhappy. Activity Be aware of objective and subjective writing Sort out the objective cards from the subjective cards.
Why do we write progress notes? The purpose of writing progress notes is: List 4 reasons Who reads the progress notes? The progress notes will be read and used by: List 3 possibilities What is done with the information in progress notes? How is the information used? What actions are taken based on the information? The information in progress notes is used to: List 4 options What information needs to be reported in progress notes? The information we need to include in progress is: List 5 possibilities Definitions Objective writing Objective writing is based on facts and observations. It is a description of what actually happened. Ask yourself what did you: Hear? Say? See? Do? Objective writing is not influenced by personal feelings or opinions. Example of objective writing At 3.30 pm Marcella returned from a walk to Albert Street Park and she was holding her right arm against her body. I noticed that she had a graze and bruise on her right arm. Marcella said a dog had jumped on her when she was sitting on the grass at the park. She said she had been frightened and that her arm was sore. Subjective writing Subjective writing is based on or influenced by the writer’s point of view, emotions, assumptions, speculation, judgement or interpretations. We are often subjective. Example subjective writing Marcella must have bumped into something when she went on a walk to Albert Street Park, as she has grazed skin and a bruise on her arm. She was holding her arm and looked unhappy. Activity Be aware of objective and subjective writing Sort out the objective cards from the subjective cards.