Progress Notes & SOAP Format Flashcards

A resident tells the recreation aide, 'I haven't been sleeping well and I don't feel like doing anything.' This statement should appear in the:

Answer: Subjective section

Direct quotes or paraphrased reports from the resident about how they feel are recorded in the Subjective section.

When writing a progress note, the aide should sign with:

Answer: Full name and title/credential

All documentation must be signed with the author's full name and title to ensure accountability and authenticity.

A resident's goal in the care plan is to 'increase social interaction.' Which progress note entry BEST demonstrates progress toward this goal?

Answer: Resident initiated conversation with two peers during craft group

Documenting a specific, observed behavior (initiated conversation with two peers) directly links to the social interaction goal.

Which of the following is an example of falsifying documentation?

Answer: Recording an activity as attended when the resident did not participate

Recording false attendance is falsification of medical records, which is illegal and a serious ethical violation.

The term 'PRN' in a recreation therapy plan means:

Answer: As needed

PRN is a Latin abbreviation for 'pro re nata,' meaning 'as needed,' commonly used in care planning.

A recreation aide notices a resident has bruising not previously documented. The aide should:

Answer: Document it in the progress note and report it to a supervisor immediately

Unexplained injuries must be documented and immediately reported to a supervisor per mandated reporter and abuse prevention protocols.

Which abbreviation correctly documents the level of assistance provided to a resident?

Answer: MIN A (minimal assistance)

MIN A stands for minimal assistance and is a standard abbreviation for documenting the level of physical help provided.