Description

This session provides an in-depth review of documentation best practices for activity and social service departments within nursing home settings. Attendees will explore regulatory expectations, interdisciplinary communication strategies, and person-centered documentation techniques that reflect each resident’s psychosocial well-being and engagement. The presentation will emphasize how accurate, timely, and meaningful documentation directly impacts quality of care, regulatory compliance, and care planning outcomes.

Objectives:

• Identify regulatory requirements for documenting activity and social services in nursing homes, including regulations and surveyor focus areas.
• Describe the components of effective documentation that reflect resident choice, participation, psychosocial needs, and individualized goals.
• Differentiate between social service and activity documentation, ensuring clarity of roles and appropriate language for each discipline.
• Apply person-centered documentation practices to accurately capture resident preferences, barriers to participation, and outcomes.
• Recognize common documentation pitfalls and strategies to improve accuracy, timeliness, and interdisciplinary collaboration.

Speaker: Linda Farrar, RN, LNHA, Oklahoma Clinical Coordinator 

NAB approval #: 20260827-1.25-A114537-DL