Fillable quarterly progress note for activity directors. Nine sections cover level, participation, response, three care plan goals, and plan changes.
WHAT IT IS
A six-page PDF for writing a complete quarterly activity progress note. Four pages are a fillable form with checkboxes and writing boxes. Two pages are writing help, with prompts and sample wording for each functional level.
THE NINE SECTIONS OF THE FORM
1. Changes this quarter
2. Functional level, with abilities compared to the last review
3. Participation this quarter
4. Interests and activity types
5. Response to programming
6. Supports and adaptations in use
7. Care plan goals: three goals, each with a status and a progress box
8. Plan for next quarter, with follow-up needed
9. Summary and sign-off
THE WRITING HELP
- Prompts for four functional levels (early, middle, late-middle, and late stage): what to look for, a sample note with blanks to fill in, and plan ideas
- A measurable-goal formula and a sample goal for each level
- What each goal status means, in plain words
- A word bank for engagement, mood, social connection, and support
DETAILS
- 1 PDF file, 6 pages, US Letter size (8.5 x 11 inches)
- Type into it on a computer, or print it and fill it in by hand
- Fillable fields work in the free Adobe Acrobat Reader
- Color-coded level headings; prints in color or in grayscale
- Use it for quarterly, annual, and change-in-condition reviews
- Save a fresh copy for each resident each quarter
GOOD FOR
- Activity directors and activity assistants
- Skilled nursing, assisted living, and memory care communities
- Adult day centers
- Care plan meetings
PLEASE NOTE
This template supports your documentation and does not replace your community's required forms or policies. The functional level is an activity-planning guide, not a diagnosis. The template uses its own Level A-D wording and does not reproduce the Global Deterioration Scale, FAST, Allen Cognitive Levels, or GEMS.
This is a digital download. No physical item will be shipped.
Created by a senior care professional with about 30 years of experience as an activity director and program director.
