Complete Guide to Progress Notes in Disability & Aged Care

Gaurav

Progress-notes   Care-notes   Shift-notes

Progress notes are a vital part of a care delivery framework and a must-have for any care delivery team.

Progress notes reflect a client's movement towards their goals, as identified in their Individual Support Plans, and also represent a record of events on each shift or visit, and thereby serve as a communication tool for staff.

By reading this guide, you can find out more about why progress notes are important, and what kind of information should be included in progress notes. You will also pick up valuable tips on how to write progress notes to a high professional standard.

What are Progress Notes in home care?

Progress notes are documents created by support workers at the end of a shift and are an essential part of a Client Personal File. In progress notes, staff succinctly record details that document a client’s status and achievements. Progress notes are a tool for reflecting on a client’s movement towards their goals, as identified in their Individual Support Plans. They also represent a record of events on each shift or visit, and act as a communication tool for staff and families.

As well as being used in home care, progress notes may be used in community care, group programs, sheltered accommodation, and nursing homes.

Why do we write Progress Notes?

We record and file progress notes for the following reasons:

  1. Progress notes act as proof of service delivery.

  2. Progress notes constitute a legal record.

    Progress notes become part of a patient’s permanent legal record. Progress notes may be used in legal proceedings, audits and investigations. They also provide a paper trail in case of conflict or difficult situations.

    It is mandatory to report incidents (and alleged incidents) to the NDIS Commission, either directly or via a s upervisor, manager, specified person, or member of the provider’s key personnel.

    Reportable incidents and allegations include:

    • Injury
    • Alleged abuse and/or neglect by a worker, another participant, a family member, another service provider, visitors, members of the community, etc.
    • Unlawful sexual or physical contact or assault.
    • Sexual misconduct.
    • Unauthorised use of a restrictive practice.
    • Death

    Progress notes recorded in the ShiftCare app may be used as evidence.

    If you are unsure of whether to report an incident or allegation, report it! The relevant personnel will decide what (if any) action is needed.

    For more information and guidance, you can refer to the NDIS Reportable Incidents Guide.

  3. Progress notes link service to care plans and help in preparing client’s plan review:

    Progress notes link service and progress to the client’s overall plan, to client goals and to individual strategies. Information from progress notes can be used to write client NDIS progress reports, which usually need to be submitted every 12 months. These reports help NDIS (or aged care decision-makers) with progress and care plan reviews, and these, in turn, help to guide the carers whose work it is to implement participant goals. Discover how to measure the outcomes on the NDIS website.

  4. Sharing Information

    Progress notes can be used to share information between carers, families and coordinators (including team leaders and managers) so that all interested parties can keep abreast of changes in patient status, routines and needs.

    For in-home services, progress notes play a vital role in ensuring transparency of care between care teams, as well as for primary carers.

    Progress notes can act as handover notes for next shift staff.

    Here are some simple examples that demonstrate how sharing information recorded during care visits can be helpful:

    Sharing information between different carers:

    A carer working with a patient in the morning records in a progress note that the patient has not eaten their breakfast. The carer coming on shift with the same patient in the afternoon has access to that information, and can make absolutely sure that the patient eats lunch.

    Sharing information between care workers and families:

    A care worker goes out shopping with a dementia patient and records the experience, including what was purchased. Having read the notes, the patient’s family can use the information as a point of conversation. Without context, it may be hard for a dementia patient to remember the morning visit to the shop, and it could frustrate them when the topic is raised. Having read the progress note, a family member can pose a detailed question, such as: “How was shopping? I understand you bought new cushions, what colour are they?” This creates a more rewarding experience for both the patient and their family.

How to write Progress Notes

A progress note is by no means the entire record of the visit. It is simply a snapshot of what transpired, including the most significant factual information. If the carer is already familiar with the client’s routines and behaviour, the main point is to note any deviation from the client’s normal routines and patterns.

Progress notes are partly generic in nature; for example, comments on a patient’s physical state and emotional wellbeing are likely to be appropriate whether the setting is mental health care, disability care, dementia care, or any kind of nursing context. Beyond this, progress notes should also relate to a client’s individual plan; to their individual goals and strategies.

All progress notes must include:

  • Your name.
  • The date and time.
  • Details of any reportable incidents or alleged incidents, including those involving peers or others, and including details of witnesses if there are any.

Other types of information that it may be appropriate to record in progress notes, depending on the specific home care situation, include:

  • Visits from health professionals.
  • Changes emotional wellbeings.
  • Carer interventions and assistance given.
  • Changes in behaviour.
  • Degree of participation in activities.
  • Behaviour of concern (what happened before, during and after).
  • Reactions to medications.
  • Concerning changes in physical appearance.
  • Dietary notes.

Here are some important guidelines to consider when making progress notes:

  • Progress notes should be recorded at the end of every shift.
  • Progress notes can be written by hand or typed.
  • Write down events in the order in which they happened.
  • Include both positive and negative occurrences, and anything out of the ordinary.
  • Record errors made by caregivers - even your own errors!.
  • Keep in mind the goals in the client’s plan. You may wish to work from different progress notes templates for different patients.
  • Write concisely, so that others can easily scan the information. At the same time;
  • Notes need to include enough information that others can understand what happened.
  • Where significant, state what occurred before, during and after and incident.
  • Use plain language that any adult would be able to understand (even if they have no specialist knowledge, speak English as a second language, or have a learning disability).
  • Consider using the STAR model to record information: Setting, Trigger, Action, Result.
  • Be specific. For example: “At 3:45pm Jane’s temperature was 39 degrees”, not just, “Jane had a fever this afternoon”.
  • Accurately describe the types of assistance given during each activity. Eg. Verbal cues, or hand-over-hand assistance.
  • Write using the ‘active voice’ rather than ‘passive voice’. The active voice places the focus on the doer of the action:
    Active Voice Passive Voice
    Mr Ryan refused to eat breakfast. Breakfast was refused by Mr Ryan.
    Staff helped Mrs Bradford to get dressed. Mrs Bradford was helped to get dressed by the staff.
    Carer found Ms Smith on the bedroom floor. Ms Smith was found on the bedroom floor.
    The nurse changed Mrs Clair’s sheets. Mrs Clair’s sheets were changed by the nurse
  • Information should be objective, not subjective. What did you see / hear / say / do? Record concrete, factual information. Do not include your opinions about the facts. (For more help with how to write progress notes objectively, see this NDS workbook

Here are examples of objective and subjective writing, taken from the same workbook:

Example of objective writing:

“At 3.30 pm Marcella returned from a walk to Albert Street Park and she was holding her right arm against her body. She had a graze and bruise on her right arm. Marcella said a dog had jumped on her when she was sitting on the grass at the park. She said she had been frightened and that her arm was sore.”

Example of subjective writing:

“Marcella must have bumped into something when she went on a walk to Albert Street Park, as she has grazed skin and a bruise on her arm. She was holding her arm and looked unhappy.”

How is ShiftCare revolutionizing Progress Notes?

  1. Recording & Sharing On-going Progress:

    ShiftCare’s Progress Notes provide a daily account of each client, their illness (if any), and developments within their care, for all those who visit that client. Carers can use the app to communicate with one another, making it easier to assess whether a client’s health is getting worse, better or remaining the same. ShiftCare’s App includes a ‘speech-to-text’ technology which allows carers to quickly and easily record progress notes. The voice notes are automatically transformed into text to be submitted.

  2. Smooth & Immediate Transfer of Handover Notes to Following Shift Carer:

    The progress notes feature in the ShiftCare app provides a way of recording relevant, on-going, and active problems. By sharing these notes between teams, via the app, problems are communicated carer to carer in real-time, with no need for a handover of physical documents or folders.

  3. ShiftCare keeps records of progress notes for audit purposes:

    Care coordinators are responsible for auditing progress notes, ensuring that carers have visited clients at the correct times, and checking for any concerns or problems that haven’t been reported to the office. With the ShiftCare app, all this information is available in one place. Records are stored securely on our server, and there is no risk of information loss. theft or damage.

Records are stored securely on our server, and there is no risk of information loss, theft or damage.