Documentation in a Snap for Activity Programs

The purpose of this book is to create a system of documentation that supports the delivery of resident care. The clinical record may be either handwritten or electronic, but its purpose is to provide the activity professional with information to:

*assess each resident's needs

*develop a plan of care

*establish goals to be achieved and outcomes expected

*document interventions

*evaluate the success or need for revision of the care plan

Throughout this book there are references specific to activity programs in nursing facilities and other situations that fall under OBRA guidelines. Federal regulations with interpretive guidelines and sections of the Resident Assessment Instrument (RAI) Version 3.0 Manual that describe documentation requirements are included.