Progress Notes

Welcome to Part 2 on the series about Record Keeping. This post is all about progress notes for therapeutic and adaptive horseback riding programs!¬†There is a lot of information in here about both writing and designing progress notes, so feel free to just read about what is applicable to you right now ūüôā Let’s begin!

Writing Progress Notes

WHAT are Progress Notes

A little review: A progress note is a report that documents the lesson with an update on the client’s current status toward their goals. At its most basic, it includes a summary of the lesson, notes on the rider’s attitude, strengths and weaknesses, whether or not they reached the objective or goal (or how close), and recommendations for the future.

WHY do Progress Notes

The benefits and purpose of progress notes are at the end of my Record Keeping Introduction post, so if you need a reminder, go check them out there!

WHAT to Record in Progress Notes

What is included on your program’s progress notes depends on what your program uses its progress notes for. However, these are the most common things I‚Äôve seen given a specific place to be filled out on progress notes.

Basic Progress Note

At its most basic, PATH Intl.’s Instructor Education Guide lists the following as what to include on a progress note:

  • Date
  • Rider
  • Instructor
  • Leader & Sidewalker/s
  • Horse
  • Lesson Objective
  • Discussion
    • whether the objective was met – be specific, give measurable reports about how closely the objective was achieved
    • what strategies/supports/conditions helped, were tried, and could be tried in the future

Additional Info

I have also seen the following included:

  • Participation: Present, Absent, Excused
  • Type of lesson: Group or Private
  • Lesson length: 30 min, 45 min, etc.
  • Assistance Needed: for each gait list leader, sidewalker, or independent
  • Affect/Attitude: such as¬†Hard Worker, Confident, Assertive, Excited, Cooperative, Social, Energetic, Frustrated, Distractible, Defiant, Withdrawn, Fragile, Anxious, Bored, Fatigued, Uncooperative, Motivated, etc.
  • Long & Short Term Goals Addressed
  • Brief Lesson Plan/Content
  • Rider’s Strengths
  • Rider’s Weaknesses
  • Horse Notes
  • Suggestions for the Next Lesson
  • Notes from the parent and/or volunteer
  • Safety Concerns
  • Other tracking info your center wants (such as rating specific abilities in order to track improvement)

HOW to Write Progress Notes

It Starts In The Arena

Remember that writing progress notes starts with paying attention when you teach the lesson and remembering what happens during it! Most importantly, keep in mind the lesson objective, and if you included a number (such as the rider will post the trot for 5 strides) then be counting. Be familiar with your barn’s progress notes and look for the information it asks for. During your conclusion or cool-down time, you can get feedback from the rider about how the lesson went and discuss what to work on next. Lastly, keep in mind the below list of things to include, as well.

What To Include

The following is a list of things that are good to include in your progress notes, when applicable. They are usually not their own “line item” to fill out, but rather expected to be included in the Discussion, Rider’s Strengths and Weaknesses, or other notes.

  • Refer to the Objective/Goal.¬†Give specific measurable reports of how closelqy the rider met the objective of the lesson.
  • Whether the Lesson Plan was followed or worked, and why or why not.
  • Prompts needed for instructions given.
  • Progressions made during the lesson, such as removing prompts.
  • Potential Barriers.¬†‚ÄúEven if progress is not observed in a lesson, instructors should take the opportunity to document potential barriers or the reason for lack of advancement in addition to a plan to encourage progress in future lessons‚ÄĚ (PATH Intl.’s Instructor Education Guide p.117)
  • Use of adaptive equipment and communication devices.
  • Appropriate or inappropriate interactions with the staff, volunteers, or peers.
  • Initiatives or prompts taken with actions, ideas, problem solving, and decision making.
  • New patterns of behavior.
  • Verbal information provided by the client.
  • Involvement,¬†and it’s extent and nature.
  • Attention shown, attention span.
  • Interest in activities.
  • Ability to make decisions.
  • Receptive and expressive communication levels.
  • Special incidents.
  • Relationships with instructors/volunteers/others.
  • Orientation of time and place.
  • Ability to remember.
  • Stability of mood.

How to Write

Here are some tips about the words you use to write your progress notes:

  • Emphasize the lesson objective. Often refer back to the lesson objective and how your comment relates to it, instead of listing just what happened in class.
  • Use simple descriptive words.¬†Describe a specific event or activity as it was seen or heard, not as subjective opinion.
  • Be objective.¬†Record only objective observations of behavior. Note when you are making subjective interpretations.
  • Be accurate.¬†Avoid generalizations or vague phrases. Provide a # of instances or a range. For example, instead of ‚Äúthe rider sat the trot‚ÄĚ, write ‚Äúthe rider sat the trot for 1 wall 6 times in 1 lesson.
  • Be clear and concise.¬†No one wants to write or read a novel ūüôā
  • Be informative. Try to provide the whole picture.
  • Be positive. Instead of stating undesired behaviors as what not to do, restate it as what the rider has difficulty doing or needs to do, and give positive suggestions. For example, instead of “The rider kept jerking the horse’s mouth around while trotting,” say, “The rider had difficulty keeping their hands quiet at trot. Next time start with the reins on the halter and have him hold the handhold strap with the goal of keeping his hands still for longer lengths of trotting.”
  • Be professional.¬†Write knowing that anyone might read this (fellow instructors, the rider’s family, therapists, etc.). Use correct grammar.

WHEN & WHERE To Write Progress Notes

The following may seem overly detailed, but it actually can greatly affect the quality of your progress notes and their use to your program. Instructors, think about these factors when planning your time! Program directors, think about these factors when designing your progress notes system!

How Often To Write Progress Notes

PATH Intl.‚Äôs Standards says to do progress notes ‚Äúon a regular basis‚ÄĚ ‚Äď it doesn‚Äôt say whether that means every lesson, every few lessons, or at the end of every session or month. However, every program I‚Äôve been to has required that progress notes be written for every lesson, probably because of all the reasons on the benefits list at the end of the¬†Record Keeping Introduction post, .

How Soon After The Lesson

In general, the sooner the better, because the longer you wait to do your progress notes the more likely you are to forget the details of the lessons or mix up the lessons. However, when you are actually able to do them is greatly influenced by the progress note system that your program uses. Here are some thoughts:

  • After each lesson
    • This is the soonest possible timing to write a progress note, but only works if you have a break between lessons, are not needed in the aisle at that time, and your progress note system/format is not time-consuming.
    • You can use your phone to write progress notes while still in the arena if your progress note system uses a program or app on your phone, such as GoogleForms or GoogleDocs (more in this great idea in the later post on methods).
    • If you do not have time between lessons to do progress notes, you can still write¬†a few short notes about how the lesson went on your lesson plan sheet or in a doc on your phone that you can use later to quickly write your progress notes. I did this and it helped SO much! On my mini lesson plan sheet¬†I simply checked off what we did do, crossed off what we didn’t, wrote in what changed, how many successes out of attempts were made, and any other quick notes about the lesson or even one word to remind me of something that happened. You could even do this with your volunteer team to get their input and fill them in on what you are thinking about your rider so they are more aware and invested.
  • After a few lessons
    • If you have a break every few lessons, hop in the office and write those progress notes!
    • If you don‚Äôt have enough time to write the actual progress notes, take a minute to write little notes about the lesson to remember for later (see the suggestions above).
  • At the end of the day
    • At the end of the day is when I have seen most instructors do their progress notes. This is because in these programs the lessons were back to back so the instructors had no time between lessons, or when they did have time they were needed in the aisle or for other work.
    • This can be a challenge for the memory.¬†When I first started instructor training, I could not imagine remembering the details of 7 lessons in a row, but one of our teachers told us that you may not believe it, but your memory will get better…and over time, it did! So keep practicing, your memory will improve.
    • If you have a hard time remembering what happened in your lessons, take short notes after each one to help you remember (see above).
    • Another challenge to doing progress notes at the end of the day is actually getting them done – sometimes by the end of the program day it’s so late or you’re so tired that you push back doing your progress notes until even later in the evening or the in the week.
  • Later in the week
    • Doing progress notes later in the week can result in forgetting details or never doing them at all.
    • If this is a consistent habit for you and/or your instructors, I‚Äôd recommend rethinking the format and system of your progress notes to make it easier and faster to get done the day of lessons!

Where To Write Progress Notes

This is also important to think about because it will affect how you write your progress notes, and similarly, where you are actually able to do them is greatly influenced by the progress note system that your program uses. Here are some thoughts:

  • At the barn
    • Doing progress notes at the barn is beneficial because you can go straight from teaching to writing, with less chance of forgetting anything.
    • It is also convenient to do them while you’re clocked in (without having to clock back in later), and to keep work at work and not bring it home with you.
    • It is also convenient if the barn has a program computer on site, so all the information stays on that computer instead of having it on your computer too.
    • Challenges to doing progress notes at the barn include that you may be tired right after teaching and therefore tempted to rush through writing them just to get home; you also are more easily distracted by socializing and more easily interrupted by questions or barn work, which can make writing progress notes take longer and keep you from being fully focused and doing your best work.
  • Not at the barn (at home, a coffee shop, etc.)
    • Doing progress notes somewhere other than the barn can be beneficial because you are unlikely to be distracted and interrupted, which allows you to work faster and think more thoroughly about your rider and your teaching techniques, therefore doing better work and reaping more benefits from the process of writing them.
    • Challenges to doing progress notes somewhere else include finding the time to do it, it’s probably been a while since the lesson so it may be harder to remember the details, you have to reclock in to work somehow, having the files on your computer as well as the riding program’s system or computer can cause difficulty if files don’t update or if there are privacy concerns, if you print progress notes at home you are using your own paper and ink, and if you print progress notes at work that is one more thing to do later.

Designing Progress Notes

Here are some more things to think about when designing your progress notes system. If you are an instructor in training, you probably don’t need this information yet. If you are a program director, this may be helpful. Keep in mind that your choices regarding the following will greatly depend on your staff’s preferences and your resources.

HOW to Format the Progress Note Sheet

How a program formats its progress note sheet can expedite the process and enhance the experience (or make it worse!). NOTE: I will go more into methods/systems/apps for doing record keeping in a future post. This specific section is about how you format what is ON your progress note sheet that everyone fills out.

Provide Blank Lines

At its most basic, progress notes have blank spaces to fill out the information. This is nice because instructors can write how they like – paragraphs, bullet points, etc. And if you are using a computer program, you can copy and paste similar information between progress notes (like lesson content).

  • Ex) Assistance Needed: ____________________

Give Options to Circle or Check

Some barns give options that can be circled or checked. This helps instructors fill out their progress notes faster because there is less actual writing to do (especially if everything is handwritten) and allows consistency of wording between progress notes if a program is tracking something. This is mostly done for the lesson data (participation, type of lesson, etc.), while leaving blank lines to fill in for the lesson discussion (rider strengths, weaknesses, etc.).

  • Ex)¬†Assistance Needed: (check for each gait)
    • Walk: [ ] leader [ ] sidewalker [ ] independent
    • Trot: [ ] leader [ ] sidewalker [ ] independent
    • Canter: [ ] leader [ ] sidewalker [ ] independent

Drop Down Options

If you use a program like Excel or some other record keeping app or computer program, you can create drop down options to choose for lesson data and even lesson objectives.

  • Ex) At one barn I worked at, they did their progress notes in Excel, and on the first tab you entered your rider’s goals and objectives, and on the following tabs where you entered your progress notes you could select from a drop down option those very same objectives you entered in the first page! (They had an Excel guru on staff).

Those are the most common formats I’ve seen, I’m sure there are others! If you have other examples, please leave it in the comments!

WHO Writes Progress Notes

Who writes your progress notes will greatly affect the time you spend on them, how you format them, and the end results. I have seen the following at barns:

The Instructor

At most programs I’ve been to, the instructor writes the progress notes.

  • This is beneficial in that the instructor is more familiar with the rider, their goals, what to look for during lessons. Additionally, the progress notes help the instructor plan the next lesson and work toward their rider’s progression, so doing the progress notes themselves may help them do this more effectively.
  • This can be a challenge in that most instructors have little time to write progress notes, so they may get done later in the day or week when the instructor may not remember the lesson as well (or, let’s be honest, they may not get done at all).
  • It may help to use a system that allows the instructor to do progress notes right after the lesson, such as on their phone or having progress notes in a binder in the arena.
  • It may help to have a designated “observer” volunteer who watches the lesson and takes notes or fills out what they can of the progress note during the lesson, which the instructor reviews and adds to later.

Volunteers

I have also seen programs use volunteers to fill out progress notes. Similarly, they could make short note sheets that are later used by the instructor to write the official progress note.

  • You can use a volunteer in the lesson (leader or sidewalker) or¬†designated an official “observer” or “instructor’s assistant” whose main job is to observe and write notes. Using an observer is beneficial in that they may notice things more fully or objectively than a sidewalker who is right beside the rider or a leader who is up in front. However, the sidewalker who is directly involved with the rider may be able to give more additional insight and observations for the rider than someone who is farther away.
  • Using volunteers can be beneficial because they have a different perspective on the lesson and may notice things the instructor does not, since they are keenly watching their one rider the whole time. Also, by becoming more involved in progress notes and aware of the rider’s goals and progress, the volunteer may become more invested in the rider, be better equipped to support the rider, and have a more satisfying volunteer experience. If you have times of the week in which you have an excessive amount of volunteers, doing progress notes is a good option for giving them something to do that can help take the work load off your instructors.
  • Using volunteers for progress notes can be a challenge in that they may not know what to look for in riding lessons, know how to write progress notes correctly (such as being accurate in how many attempts, successes, etc.), know much about horses or riders with disabilities, and may not be familiar with that particular rider‚Äôs goals. However, these are all things you could train the volunteer in. When the program I was at used this method, I sat with the volunteers at the end of our session of lessons and we wrote the progress notes together.
  • To mitigate the above challenges you could set up your progress notes to ask for more specific information that cues the volunteer what exactly to look for, and include the lesson objective and long term goals already listed on each sheet for them.
  • Another challenge is inconsistent volunteers. If your program has difficulty keeping the same volunteers with riders, there may be inconsistency between progress notes and you may spend excess time training volunteers how to write them.
  • Lastly, the instructor is still ultimately responsible for all their riders’ progress notes, even when done by volunteers, and still needs to make sure the notes are done timely, accurately, and correctly.

Remember

Keep in mind the purpose of your program’s progress notes when deciding who will do them. It seems to me that if your progress notes greatly help your instructors to plan future lessons and encourage rider progression, then they probably should do them themselves (or if someone else writes them then the instructor should be expected to review the progress notes weekly when lesson planning). If the progress notes are kept primarily for recording reasons, their use for end of the session/year assessments, and instructors do not use them as much on a weekly basis, then it may be better for volunteers to do them to save the instructors’ time.

Examples of Progress Notes

Examples of BLANK Progress Notes

Here are some examples of blank progress notes and how different barns might adapt them to their needs. Note the formatting is not the best because I’m not attaching the actual documents.

Example 1)¬†PATH Intl.’s Instructor Education Guide’s progress note:

Rider:

Date:                              Horse:

Leader:                          Sidewalker(s):

Lesson Objective:

Discussion:

(Signed by Instructor)

Example 2) What I’ve seen at a few barns – the options can be circled if by hand or underlined if on a computer:

Instructor:

Client name:

Date:               Week:               Quarter: Winter/Spring/Summer/Fall

Participation:  Present/Excused/Unexcused

Affect: Excited, Social, Cooperative, Uncooperative, Frustrated, Distractible, Defiant, Withdrawn, Anxious, Bored, Fatigued

Goals Targeted:

Lesson Content:

Rider Strengths:

Rider Weaknesses:

Suggestions for Next Lesson:

Example 3) Horsepower TR (thank you Carrie!) Рnote there are two of these on a page, lots of check boxes, and less room to write, as they are designed to be filled out by hand quickly

Student:

Billing Lesson # ____ / ____     Overall Lesson #  _______      Date ___________

Horse  __________            Instructor Initials  ______

[ ] 15min (sib ride)    [ ] 30min   [ ] 45min   [ ] 60min   [ ] 90min

[ ] groom & tack   [ ] ground wk   [ ] ride   [ ] vault   [ ] other___________

Activity/Game/Lesson Plan: ______________________________________________

____________________________________________________________________________

Walk:   [ ] Lunge Line   [ ] Leader   [ ] Sidewalker   [ ] Independent  Notes:___________________________________________________________________

Trot:   [ ] Lunge Line   [ ] Leader   [ ] Sidewalker   [ ] Independent  Notes:___________________________________________________________________

Canter:   [ ] Lunge Line   [ ] Leader   [ ] Sidewalker   [ ] Independent  Notes:___________________________________________________________________

[ ] Hard Worker   [ ] Confident   [ ] Assertive   [ ] Excited   [ ] Cooperative   [ ] Social   [ ] Energetic   [ ] Frustrated   [ ] Distractible   [ ] Defiant   [ ] Withdrawn   [ ] Fragile   [ ] Anxious   [ ] Bored   [ ] Fatigued

Comments:____________________________________________________________

Plan for next ride: ________________________________________________________

Example 4) Amy’s example of lesson and progress note (thank you Amy!)

Name:

Date:

Riding Level (if new or changed):

  • Walk onlead
  • Walk offlead
  • Trot Onlead
  • Trot Offlead
  • Other…

Tack Needed  (if new or changed):

Volunteers Needed  (if new or changed):

Objective Riding Skill for the lesson:

Measurement (length of time/distance/etc.):

Props Needed and Layout:

Lesson Content:

  • Warm-up/Stretches
  • Skill taught/refreshed
  • Skill enforced
  • Game/Activity
  • Cool Down/Trail ride

Post Lesson Review:

Skills to Work On:

Example 5) D’s post on the PATH Intl. Instructor Community Forums:

Participant:

Instructor:

Horse:

Today’s Date:

Attendance:

  • Lesson Attended
  • Planned absence
  • Unplanned absence
  • No call, no show
  • Lesson Cancelled, Inclement Weather
  • Schedule week off
  • Lesson Cancelled, other
  • End of session summary

Attendance Note: (if they didn’t come)

Date Goals and Objectives were set:

Long Term Goal:

Lesson Summary:

Session Objectives:

Progress on Objective 1:

  • Not attempted
  • Attempted
  • Developing
  • Partially met
  • Fully met

Progress Notes on Objective 1:

(Repeat for any additional session objectives)

Examples of WRITTEN Progress Notes

Here are examples I made up using some of the above progress note formats, with varying amounts of detail. Hopefully they are good examples of always referring back to the objective and including the important information and writing styles listed earlier.

Example 1)  Here is an example of a minimal detail progress note using the format from Example 1/PATH Intl, similar to the example of a good progress note in the PATH Intl. Instructor Education Guide on page 118:

Rider: Bob

Date:  4/5/2015                            Horse: Garfield

Leader: Roshanna                         Sidewalker(s): none

Lesson Objective: Bob will demonstrate posting trot for 1 lap of the arena without a leader.

Discussion: Bob accomplished the lesson objective by posting the trot for 1 lap 3x during the lesson. Bob effectively used his aids to cue walk-trot and trot-walk transitions and to direct rein steer his horse without a leader and with some assistance from the TRI to keep his horse on the rail. He needed minimal verbal prompts from the TRI for correct hand posture and to use the aids stronger. Bob worked very hard today, focused well, and had a great attitude despite his horse’s difficult behavior of not wanting to stay on the rail. He even progressed to trotting a smaller lap using half the arena 2x in each direction.

In future sessions continue to work on the posting trot: on his own remembering to post instead of sit the trot, on picking up the correct diagonal, and on smaller circles. Despite weak core and arm strength, he showed patience and persistence when his horse continuously pulled on the reins and came into the arena. Consider schooling Garfield before the lesson or having the leader stay close so Bob can focus on his posting trot more than keeping his horse straight.

(Signed by Instructor)

Example 2) Here is an example of a moderately detailed progress note I made up using D’s form from above’s Ex. 5:

Participant: Bob

Instructor: Cindy

Horse: Garfield

Today’s Date: 4/5/2015

Attendance: Lesson Attended

Attendance Note: x

Long Term Goal: Bob will ride independently at the trot.

Lesson Summary: Bob worked on posting the trot for a full lap of the arena without a leader, which he accomplished, and progressed to trotting a circle using half the arena around guide cones. Bob worked very hard today, stayed focused, and had a great attitude despite his horse not wanting to stay on the rail.

Session Objective 1: Bob will demonstrate posting trot for 1 lap of the arena without a leader.

Progress on Objective 1: Not Attempted, Attempted, Developing, Partially Met, Fully Met

Progess Note on Objective 1: Bob is successfully posting the trot for a full lap of the arena when the TRI helps keep the horse on the rail. He still needs minimal verbal prompts to remember to post, and for correct hand posture, and to use the aids stronger. He was more successful to the left (2/3 attempts) than the right (1/3 attempts). He progressed to trotting a circle on half the arena around guide cones, 2x each direction. Next time work on picking up the correct posting diagonal.

Example 3) Here is an example of a progress note I made up that is very detailed (and how I used to do them):

Instructor: Cindy L

Client Name: Bob

Date: 4/5/2015      Week #: 4

Quarter (circle):   Winter     Spring    Summer 1    Summer 2    Fall                                 Participation (circle):     Present       Excused Absence       Unexcused Absence

Quality of Participation (circle):  Motivated         Withdrawn          Uncooperative          Distracted         Overly Energetic       Other:

Goals Targeted:

Improve independent riding: Bob will demonstrate posting trot for 1 lap of the arena without a leader.

Lesson Content:

(Note: I copied and pasted this from my mini lesson plan and added some notes)

  • Lead horse 1 lap and through weaving cones, to black block, Leader spot
  • Mount ‚Äď min VP, croup, block/stairs, with L, TRI min assist
  • Warmups ‚Äď arm circles, 2 point, around the world at the halt then at the walk, with L, SW spot
  • Steering ‚Äď walk 1 lap, no L
  • Posting trot ‚Äď 1 lap each direction, no L, TRI spot to keep horse on the rail
  • Progress to trot in circle on half of arena around poles, first half the circle 3x, no L, TRI standing at trot-walk transition spot to help stop horse if needed, then progress to trotting the whole circle 2x ‚Äď practiced each direction
  • Dismount ‚Äď ground, min assist

Client Strengths:

Bob accomplished the lesson objective of posting the trot one full lap 3x today without a L! Additionally, he led his horse easily on his own with L spotting and no prompts except to remember where to go. Direct rein steered his horse 100% of the time at the walk and the trot without a L (except for the mount, warmup, and dismount), did need a spot to keep the horse on the rail at times and needed minimal verbal prompts for correct hand posture and to use the aids stronger. Had the best control and contact at the sitting trot. Bob worked very hard today, focused well, and had a great attitude and persistence despite his horse’s difficult behavior of not wanting to stay on the rail.

Client Weaknesses:

Weak core and arm strength to control his horse when she pulls on the reins, but he’s doing his best for his size despite his horse testing him a lot. Needed verbal prompts to remember to start posting instead of sitting the trot, but picked up the correct rhythm every time.

Suggestions for Next Lesson:

  • Next week review and practice posting on the correct diagonal (his next goal).
  • Keep leader or TRI close to horse so she doesn‚Äôt come in off the wall.
  • Continue practicing independent trotting by staying off the rail, working around cones, and with the TRI close to help when needed, as his horse is less likely to try to come in to the center of the arena.

I hope that was helpful! If you have any ideas to add or examples, please leave them in the comments or contact me and I will include them! Now stay tuned for next week: Assessments!

Sources

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Note: This is not professional advice, this is a blog. I am not liable for what you do with or how you use this information. The activities explained in this blog may not be fit for every rider, riding instructor, or riding center depending on their current condition and resources. Use your best personal judgement! If you would like to contribute an activity or article, please contact me here, I would love to hear from you!

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