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How to write progress notes

If you're an aged care worker you will spend a great deal of your time collecting information about clients, maintaining care records and documenting any changes in care. Progress notes are records of an individual's ongoing care needs. 

Whilst paper work may take you away from hands on care it's a vital part of your role as a care worker. Learning to write progress notes effectively can take some practice. But aged care workers must know how to accurately take progress notes and record changes in an individual's health. 

Caregivers at home can also benefit from taking notes and recording information about a loved one's health. Often small observations can give us clues to an individual's wellbeing. For instance, recording a pain diary can help carers better understand a person's pain. 

Aged care services keep a range of documents detailing the care of their clients. Progress notes are legal documents and must be filled out correctly. As an aged care worker you have a responsibility to your employer to keep and maintain accurate records.

The written documents you are asked to keep will depend on your role and job description. Some aged care employers will expect you to write daily progress notes at the end of your shift, others will only ask you to write exceptional reports (unusual incidents and events such as a fall).

Here are some general guidelines to help you improve your documentation skills.

Tips for Writing in Progress Notes 

  • Write events chronologically as soon as possible after they occur
  • Be concise 
  • Avoid subjective sentences "The client seems upset"
  • Use plain English
  • Ensure notes are legible
  • Always use black ink
  • Be factual and precise
  • Be timely, record accidents and incidents promptly
  • Ensure you date, time and sign off on your care notes