How to Write NDIS Progress Notes That Are Actually Helpful
NDIS progress notes help care providers and support workers plan better interventions and evaluate ongoing support and care for their clients. Progress notes contain information about the support delivered during a shift, helping health service providers and loved ones stay informed about a patient’s condition and the progress they’ve made so far.
In this post, we’ll talk about how you can write better progress notes. But first, let’s take a look at what progress notes in disability support are and why they are important for providing high-quality care.
What Are NDIS Progress Notes
NDIS progress notes (also known as care notes or support logs) are end-of-shift documents created by support workers to report positive and negative incidents relating to their client that occurred during the shift.
Progress notes in disability include important information about a client’s progress, goals, events, and support plans. This helps healthcare providers, staff, and others effectively communicate with each other, make shift transitions smoother, and provide better assistance to the client.
Why is Progress Reporting Important?
Progress notes are official documents that can be made part of the legal record for audits, investigations, and legal proceedings. Well-written progress notes help disability care service providers improve their delivery of care, pass NDIS quality audits, and claim legal protection.
Moreover, care notes guide health professionals to implement participant goals and are critical to high-quality service delivery. They help keep the families, healthcare providers, and coordinators (including managers and team leaders) updated about patient status, needs, and routines.
Details included in progress notes can be used to write client NDIS progress reports – detailed documents that help NDIS (or disability care decision-makers) with monitoring care progress and plan reviews.
Essential Elements of NDIS Progress Notes
Elements that need to be included in all progress notes in disability support include:
Date and time
Information that is vital to the client’s care plan
Details about significant incidents (including alleged incidents) involving the client and information from witnesses, if any
A progress note does not need to include everything that happened during a shift, only the significant factual details. If you’re already familiar with your client’s behaviour and routines, you should only record any deviations from their regular patterns.
For more information on progress notes in disability, you can read the complete guide to progress notes in disability & aged care.
Now that you know what progress notes in disability support are and why they are important for high-quality care, let’s take a look at some of the best practices for writing better progress notes.
How To Write NDIS Progress Notes
Here are some of the best actionable tips that’ll help you get better at writing progress notes in disability:
#1: Record Objective Information
Good progress note writing starts with recording information objectively. This ensures that you report only concrete and measurable facts. You should document what you witnessed (both positive and negative occurrences), initiated, and what happened before or after an incident.
Objective writing is based on observation and facts. Consider using the STAR model (setting, trigger, action, result) shown below to record information. Answering questions given in the template will help you objectively describe events and create better progress notes:
You should record any event or situation as soon as possible. Accurately record events in the order in which they took place by including specific time stamps and dates. Avoid writing subjectively as it cannot be measured and reflects your assumptions or opinions.
If you want to describe the client’s mood or behaviour , you can use subjective words like ‘restless, agitated, and eager’. This description will be helpful for the health professional to accurately assess the client’s condition.
Here’s an example of progress notes in disability support written subjectively and objectively:
Mrs. Gardener woke up in the middle of the night. We chatted a little and watched TV for half an hour. She brushed her teeth and went to sleep.
At 11:30 pm, Mrs. Gardener woke up and went back to sleep at 12:00 am.
Timothy had high blood pressure this evening
At 6:00 pm, Timothy’s blood pressure was 130/90
#2: Write Concisely
Use fewer words to convey your message. You should be specific, accurate, and to the point. Writing concise progress notes in disability will enable other support workers to review your progress notes quickly and reduce your time spent writing.
A good practice is to keep your progress notes short while recording everything that happened. Here’s an example of the same care note entry written in wordy and concise manners:
This afternoon Peter started coughing heavily. He seemed a bit tired as well. I gave him cough syrup which he refused to take but after I insisted, he complied. The syrup successfully suppressed his cough.
At 1:45 pm, Peter started coughing so I gave him some cough syrup which stopped the coughing.
Rebecca has been doing mobility exercises for two weeks. She walked around the house without her cane this morning.
At 7:30 am, Rebecca did her mobility exercises and walked without assistance.
#3: Use Active Voice
If you write a progress note in a passive voice, you may sound impersonal, difficult to understand, and even forget key pieces of information.
In contrast, if you write in an active voice, your progress notes will be easy to understand. To make sure you record entries in active voice, focus on the doer of an action rather than the receiver of the action. Here’s an example of the same progress note entries written in active and passive voice:
Miss Ella was escorted to her room by the staff
Staff escorted Miss Ella to her room
Medication was refused by Robert
Robert refused to take his medication
#4: Avoid Acronyms and Abbreviations
Some readers may find it difficult to learn and remember new acronyms, so we suggest that you always use the full word/s where possible to avoid miscommunication. However, you can use acronyms when your readers need to know them or when they are familiar with the full term such as HIV/AIDS. If your management has an approved list of acronyms and abbreviations, you can use them in your progress notes.
#5: Don’t tamper with Entries
The importance of proper documentation in disability care cannot be overemphasised. Failure to properly document a client’s condition, medications administered, etc. can lead to poor outcomes for your clients. If you make a mistake or find a mistake made by another caregiver, simply draw a single line through the error. Never use white-out or scribble out a wrong entry. You’ll also need to make a note (along with your sign and current date) next to it, describing the error.
#6: Read Existing Progress Notes
Always read existing progress notes at the start of each shift to have a clear understanding of your client’s usual behaviour and the kind of support that will be required. This will also help you become aware of changes and exceptions to a client’s diet, medication, behavior assessment, physical appearance, physiotherapy, and occupation therapy.
Moreover, reading existing progress notes will enable you to record your entries with clarity and organise your information better. You can easily record, review, share progress reports using an NDIS care management software.
Good progress notes are crucial for providing high-quality care. By following the tips we covered in this article, you’ll be able to produce higher quality NDIS progress notes that enable carers and disability service providers to better understand, communicate, and plan carer interventions and ongoing support for your clients.
ShiftCare is a complete NDIS software for small providers that lets your care staff easily record progress notes using their phones and share them instantly with their team.