How to Write Good Nursing Progress Notes for an Adult Day Center

An adult day center provides a person in need, either due to a physical or mental disability, with supervised care during the day if a family member is unable to care for them. The person in need of care may be elderly and unable to be left alone or they may suffer from a physical problem. If a family member works or just needs some time to themselves a loved one can be cared for at an adult day center. An adult day center provides a safe and supervised environment. Nutritious meals and social functions, including crafts, are available for them to enjoy. A nurse is part of the staffing of an adult day center and will monitor the individual and document the findings with a progress note.

Instructions

Daily Observations at an Adult Day Center

• 1

  Document the person's daily activities while at the adult day center. You can state your observations on what took place while the person was staying at your facility. You can write a progress note on their activities, listing each one with any observations and behavior observed while the activity was taking place. You will want to detail if they readily participated in the activity or if they needed encouragement and if so, how much encouragement. Your progress note should state any unusual behaviors or difficulties with the activity that they were involved in. You can also observe and document their socialization skills toward other people at the adult day center, including staff members.

• 2

  Observe how the person attending the adult day center is eating. Note how much they eat and what types of food they choose to eat. Did they eat adequately, including fluid intake? This should also be noted in the nursing progress note. You may also document any physical difficulties they had while eating their meals. Suggestions may be made, based on your observations, on any types of special utensils that may be available for the person to make eating more enjoyable or easier for them.

• 3

  Chart any medications that were administered while the person was under your care at the adult day center in your nursing progress note. Did they complain of any type of discomfort or anxiety that required medication while they were at your facility? Detail in writing the type of discomfort and any symptoms they had. Note the name of the medication and the correct dosage given. Follow up with the effectiveness of the medication and any further complaints by the person in your care.