Progress Notes in Aged Care with Examples: How To Write & Manage Them Effectively
In this guide we look at how to write progress notes for Aged Care with Examples.
Writing and managing progress notes is an important part of daily operations for NDIS, nursing and aged care providers, and other health-related organisations in Australia.
Maintaining them not only constitutes a legal obligation, but also an extremely useful tool for carers to provide their clients with the best possible service.
What Are Progress Notes in Aged Care?
Progress notes are health-related records containing important developments of their progress status in relation to the supports provided.
These are created by support workers or nursing staff and contain useful information that shows how successfully participants are moving towards meeting their goals.
Progress notes also act as a tool for internal staff members to communicate the client’s current status as well as improve on current policies and procedures.
They can also be beneficial when providing an overview of a client’s progression through time, in order to spot errors and any areas that need to be improved.
Why Progress Notes Are So Important
Progress notes are used in a variety of settings, including community care, group programs, sheltered accommodation, and more.
They are critical to the success of these programs.
Documented progress notes also constitute a legal record and are official evidence of the delivery of services, potentially making them a liability if handled incorrectly.
These play a critical part in reporting incidents or allegations in relation to injuries, abuse, neglect, sexual or physical harassment and even death, to the Aged Care Quality And Safety Commission.
Progress notes are used to study the progress made by clients toward their goals and provides further guidance to carers.
Coordinators use these reports to study the progress made by clients and review their plans, providing further guidance to carers.
Providing a comprehensive summary of support services offered to the participant is only one part of the job though… Progress notes must also show how the supports helped improve the participant’s functional abilities for the duration of their plan.
This can be done effectively with HCP/CHSP management software like Brevity since it automatically applies timestamps to each progress note and provides you with a complete timeline.
Progress Notes in Aged Care as a Communication Medium
As mentioned earlier, progress notes also act as a platform through which carers and clients’ families communicate information about clients. For instance, a patient may be scheduled to participate in daily walks as per their carer plan.
If the client refuses to walk during the morning, the carer on shift may add this info into a progress note so that the next carer scheduled to come in knows about it.
Family members of clients may also find it useful to know what activities and events their days consisted of to make engaging conversations with them.
This is up to the Aged Care provider to offer but it ensures that the participant can live a better life with those around them even when they’re on their own.
How To Write Progress Notes in Aged Care Accurately
Progress notes are typically created at the end of each shift or session with the client, to ensure that any developments are recorded without delay on a regular basis.
Events recorded must be written in chronological order and may be either handwritten or electronically typed.
Progress notes must include both positive as well as negative developments and be written impartially, including any errors made by the carers.
Notes must be specific and informative, but also succinct and clear.
They must be written in plain English and be easily comprehensible by anyone who reads them. Accuracy is of the utmost importance when it comes to progress notes.
It is a legal requirement that progress notes contain factual information. This information cannot be subjective and contain the writer’s opinions, assumptions and emotions. If any interpretations or emotions are included, they must be accompanied by solid evidence as to why those interpretations were made.
Writing sentences in “active voice” is recommended as opposed to “passive voice”, in order to emphasise the doer of the tasks recorded.
We’ll explore some examples in just a few moments.
At their most basic, progress notes must include the following components:
- Participant’s name
- Carer’s name
- Date, time and the total no. of hours or quantity of support given
- Details of the type of support delivered
Any information that has a significant impact on the client’s care plan or the adherence to it, must be included in progress notes.
These include visits from health professionals, changes in behaviour and emotional health, carer interventions and support delivered, degree of participation in activities, reactions to medication, changes in physical appearance and dietary notes.
Correctly Written Progress Notes Examples for Aged Care
Progress notes must be written as accurately and as specifically as possible, in a succinct manner while still managing to be easily understandable.
The following daily care notes sample shows you a note that is written too ambiguously, containing unnecessary information, while also missing important information.
Below are some progress note examples for aged care. The correct way to write the same note is shown on the right:
Mrs. Brown reported having a stomach ache in the afternoon. It was decided that she should not go on the scheduled visit to the shops today.
Mrs. Brown said she is having a stomach ache at 12.30pm. [Manager’s name] ordered not to take her out on her scheduled outing today.
Writing sentences in active voice is favoured.
If notes are written in passive voice, the carer may accidentally exclude key pieces of information. See the following example for a visualization of this:
Mrs. Brown was found on the floor at 3.30pm.
[Carer’s name] found Mrs Brown on the floor at 3.30pm.
Notes must also contain objective information about participants and events and not contain the writer’s opinions and assumptions.
Here is an example of this:
Mrs. Brown must have had food poisoning, as she vomited today in the evening.
Mrs. Brown vomited at 5.15pm.
Use the examples above to train staff (or yourself) on best practices for recording progress notes in a meaningful way that reduces your legal liabilities.
Storing & Organising Progress Notes
All progress notes must be stored and organised appropriately. If they are made electronically, they must be stored in a secure manner and on a protected server by law.
Information loss, theft or damage must be prevented at all costs. This is the reason why documenting progress notes manually may not be the best solution for providers.
When choosing to store them on a cloud-based service such as Brevity, you are able to access your records via a variety of devices securely, including your mobile phone.
You may use the mobile application to authorise only specific staff members to access that information, or have on-site contractors write progress notes on the fly.
Good Progress Notes Make for a Great Organisation
Progress notes must be reported to management as needed. It may be a good idea to have a team leader go through progress notes to gain feedback from them prior to finalising them.
Depending on the policies and procedures of your organisation, managers may review progress notes on a regular basis (whether it be weekly or monthly).
Staff members must know who will see the information on the progress notes and that they comply with expected standards and meet set requirements.
In this article we have looked at how to write progress notes for aged care with examples. Writing good progress notes leads to not only good practice when it comes to handling progress notes but also a better organisation for both participants and employees.
It’s truly a win-win scenario!
Originally published Mar 24 2021