The following are good habits to practice when completing progress notes:
• avoid bias language
• accurate, brief
• note unusual behavior
• quotes are powerful
• include incident reports
• include date, time, signature
• explain why the Recreational Therapist is needed
• include both positive and negative aspects of the individual’s progress
• focuses on the major, substantial functional limitations that define disability: receptive language, expressive language, mobility, economic self-sufficiency, ability to perform activities of daily living, self-direction, ability to learn, and socialization
• note the ongoing goals
• use the individuals’ first name or alias – do not use “patient”, “client”, etc.
• abbreviations are not required
• medical terminology is not required
• no need to refer to yourself as “CTRS”