These progress notes are an essential way in which important information pertaining to the service recipient is communicated between team members, Coordinators and the service recipient themselves. As well as showing proof of service delivery, progress notes can also help inform future care plans, leading to better outcomes for the service recipient.
Whilst progress notes are not a record of the entire service, they do provide a factual snapshot of what transpired at the service.
As a guide, progress notes should always contain:
• Your name
• Your position title
• Date and time
• Details of tasks or duties performed at the service
Progress notes may also contain the below information (where relevant):
• Visits from healthcare professionals
• Visits from others at the service (for example friends or family of the service recipient) where they stay for a period longer than 15 minutes
• Changes in the physical or emotional well-being of a service recipient
• Carer interventions or assistance given
• Reactions to medications
• Dietary notes
• Concerning changes in physical appearance or behaviour
• Whether or not you have submitted an incident report
It is important to note that progress notes should be completed at the end of every shift and should record events in the order that they occurred. Progress notes should also attempt to relate to the service recipient’s individual care plan and their own unique goals and strategies.
What should I remember when completing notes?
- Keep notes timely: Write your notes at the end of every support. Writing down your observations, what was done and any specific achievements towards a goal.
- Use complete terms: Write out complete terms whenever possible instead of abbreviations.
- Remain objective: Write down only what you see and hear. Avoid giving your own interpretation.
- Note all communication: Jot down everything important you hear regarding a client during conversations with family members and other providers. Always designate communication with quotation marks.
- Keep it simple: Notes are meant to be quickly read.
What is an example of a progress note?
An example of a progress note is:
“Attended service at 0900 to provide a personal care service. Client John Doe was in bed on my arrival. I picked up all the laundry for the wash, put away the dishes, and went to wake John at 0915 for his 0930 medication. John chose to stay in bed for the rest of the morning watching TV until his OT appointment at 1100. I vacuumed and cleaned the toilet while keeping an ear out for John if he needed me. Before his OT arrived, I assisted John with getting up and getting ready. His neighbour came round with some oranges for John after his OT appointment. John appeared well, no injuries or difficulties during the shift. I finished at 1230.”
How do you complete your service notes?
- If you are providing supports to an NDIS Participant, you will have been emailed a link by your Coordinator prior to the service.
- If you are providing supports to a Home Care Package consumer, there will be a Communication Book located at the consumer’s home (within their home care folder). Please complete these notes by hand and leave at the consumer’s home.
- If you have any questions relating to your progress notes or what to include, please speak with your Coordinator on 1300 764 433. Please note that any incidents, hazards or feedback still need to be lodged through ionMy.