NDIS and Aged care participants along with all those who need support are generally ones who require a detailed progress review of how these people are doing and what can be done better. Progress notes or care notes can be used in many different circumstances such as legal or documentational. NDIS requires a progress report submission at the end of each year to highlight the goals and objectives set in a care plan during the start of the year.
An NDIS funded participant has some goals, objectives and strategies attached to their care plans, these care plans are formulated keeping in mind their current situation, their available funding and their priority for healing.
The goals here are important as progress notes or care notes generally specify the client's movement or deflection from these goals.
Care notes are small documents that are created by support workers at the end of a shift and are essential to documenting a client’s progress. These notes are a record of all client’s achievements and deflections. Progress notes or care notes also help reflect on a client’s care plan and can help objectively identify which shifts or days yielded most benefit towards their care plan in general.
Care notes are also an effective communication tool for supervisors to keep track of the care plan and for all support workers to also document the same without remembering them for an end of year analysis.
Care notes are prevalent for every client and hence writing them in an efficient manner should be the foremost priority for support workers.
There are many reasons to write a progress note or a care note, some of them are:
They constitute as a proof of the service delivered. Care notes at the end of every shift contribute as a proof that the shift or the service was delivered effectively.
They can be used as legal records for proceedings and investigations. Care notes are official and legal records that can be submitted as evidence for court hearings and investigations. Incidents (or alleged incidents) are mandatory to be reported to the NDIA commission directly or indirectly. Incidents that need to be reported can include but are not limited to injuries, alleged abuse or neglect, sexual assault or misconduct or unauthorised use of restrictive practice and deaths. Most incidents that you are unsure of reporting are the ones that you should absolutely report as they can be useful for varied purposes.
Like we have mentioned above, care notes can be extremely useful in developing the yearly progress plan for NDIS patients. Information from these progress notes can be effectively used to prepare a plan that best describe the client’s movement towards the identified objectives and goals.
Sharing information is another essential aspect for care notes. Information for NDIS and aged care clients is very crucial and should be shared regularly to maintain an upmost level of care and to create an open communication regarding every service they receive. If one support worker feels that the client is worse than they were today, then all the sub sequent services should have that information and supervisors should act accordingly. Sharing efficient care notes also makes it easy for client handover and change of worker scenarios.
Sharing information can also be relevant when family members want to see the progress of the client or want to understand their shifts. Reading the notes can also give family members a point of conversation to indulge with the client. Information sharing is good for these clients as it helps them stay engaged and connected to all the people in their lives.
Moving on to the usage and application of these care notes, let’s try and see how to write these care notes in a way that yields effective results for both the support workers and the client.
Think of a progress or a care note as a summary or a meta description for a page. It does not include everything that happened during the shift or the day but records the main or the crucial factual information that transcribed during the day. Progress notes or care notes are supposed to be objective and contain only facts, they are not supposed to have your own views or interpretation of the situation. They should also relate to the client’s individual goals and objectives laid out in their care plan. The general appearance and state of mind is crucial but noting their progress or deflection from their goals is the main reason for writing these progress notes.
There is certain information that all progress notes must include is:
This information mentioned above is essential, however, there can be a lot more in the care notes which include but is not limited to:
Notes should be recorded in active voice and should not include your own opinions or inferences; they should signify what was the course of action and events thoroughly.
Some other important things to note could be to include the type of assistance given, to write in plain and simple English that people can understand and to describe all the important facts.
Information should be objective rather than subjective and hence this workbook can help you more with how to write care notes objectively.
At eZaango Care Partners, we believe in differentiating from the masses and hence give you a technology and software that you love and would want to use every day rather than just charging you for a bunch of features that you never use.
For care notes to be particular, we have the option to fill out these care notes on the mobile app and the desktop software which makes it easy for support workers to write about any change as and when it occurs. Support workers can easily leave all the care notes while ending the shift. These care notes are reflected to the supervisor and can be accessed for each and every shift, if required. These care notes also help the supervisor audit support workers and understand how effectively they are working.
We also have customised solutions catered to your needs, so you get to decide what details of fields (if any) you want in your care notes.
Our team of experts have also curated specialised incident reports that help you report an incident involving the client. Incidents are mandatory to report according to the guidelines of NDIA and reporting an incident in the correct manner can help with storing and using this information later on when required. Our incident reports help you fill out all the necessary information about the incident while also taking information about the witnesses or the environment of the incident. The incident report also gives you an option to attach any image or proof if you have.
These incident reports are stored in the system and can be accessed anytime for legal or investigation purposes. These can also be useful for planning the care plan of the client moving forward and helping them achieve their goals in a better manner.
Have more questions about our software? Give us a call at 0480 208 592 or contact us at https://ezaangocarepartners.com.au/contact/ to answer all your questions.