Love or hate them, progress notes in aged care and the NDIS are vital to your care delivery and client management.
First and foremost, they enable critical care details to be shared between team members and loved ones, and help you better keep track of a participant’s progress over time.
Writing great progress notes also ensures you’re staying compliant with industry regulations, especially when it comes to being audited – and that’s exactly what this article will focus on today.
You may remember a previous post where we explained HOW to write progress notes[CM1] that are more effective and compliant. Well, now it’s time to look at WHY.
Compliance is one of those challenges that none of us wants to have to stress over, and understanding why progress notes are so important can help make staying compliant a much easier process moving forward.
In this article, not only will we explain why detailed progress notes are the key to meeting compliance requirements, but we’ll also explore one of the best tools for managing your progress notes to help streamline this for your NDIS or aged care business.
What do NDIS and aged care auditors look for in your progress notes?
For most NDIS providers, you’ll typically be audited every 18 months or so. You’ll likely also conduct your own NDIS internal audits as well to help review and improve your compliance over time.
While progress notes are by no means the only thing auditors will examine, they are a key component of the process.
Why?
Essentially, reviewing progress notes in aged care and the NDIS enables auditors to determine whether you’re:
- conforming with NDIS regulations when working with clients,
- acting in their best interests,
- providing assistance in line with their care plan,
- upholding a certain standard of care delivery, and
- including critical care details to keep all stakeholders updated.
As part of this, auditors will also consider documentation standards, as well as your ability to comply with NDIS Privacy and Confidentiality Standards.
So, what separates great progress notes from the poor ones?
As an NDIS or aged care provider, you’re always going to have your own methods for how to write progress notes.
However, there are several key factors to keep in mind when creating progress notes and conducting NDIS internal audits to ensure they’re always of a high quality:
Do they contain all the most important details?
Progress notes are essential for reviewing and updating care plans, so they need to be accurate, detailed and contain the necessary information to make the right decisions.
This doesn’t mean listing absolutely everything that happened during an appointment, just any significant incidents or details that could influence the client’s journey.
Using NDIS progress notes templates can be beneficial here to prompt care staff for the most important information.
Are they well-structured and easily readable?
A clear structure is crucial not only for writing progress notes, but also for other stakeholders to be able to understand them and gather information.
Again, using NDIS progress notes templates can be very beneficial for you and your team to ensure all your care notes follow the same clear structure and documentation standards.
Are they written objectively or subjectively?
Essentially, writing objectively means that your progress notes contain only real and measurable facts from each appointment.
Personal opinions, subjective points of view or vague observations are not necessary in your care notes, and will only risk confusing the reader.
Do they use full terms over abbreviations?
Unless you can safely assume that anyone reading the note will be able to understand a certain abbreviation, always opt for using the full term instead.
This eliminates any confusion that could lead to poor decision-making in future care delivery.
By following these tips for how to write progress notes in aged care or the NDIS, you can feel confident in your compliance levels when your next audit comes around.
Of course, the best tip we can offer is to use an NDIS management software solution that makes all of this super simple for you and your team.
ShiftCare is purpose-built to support your client notes and documentation for better compliance results
At ShiftCare, our NDIS management software makes recording, tracking and sharing client progress notes a breeze for you and your team, helping to keep everyone in the know.
As part of this, the ShiftCare app offers several advanced features to help you feel more confident in your compliance at all times, including:
Speech-to-text note taking – care workers can simply record the visit/appointment or talk directly into their phones to automatically create and transcribe detailed notes on the go
- NDIS progress notes templates – create customised care note templates so your staff know exactly what information is required and can simply fill in the blanks
- Access and privacy control – control who can view notes to maintain privacy and ensure you’re only sharing confidential client details with certain people
- Upload supporting documents – from images to forms, your staff can upload a range of documents to support their notes and client progress
With all this and so much more, ShiftCare makes conducting NDIS internal audits and passing external audits so much simpler, helping to dramatically reduce the stress and burden of staying compliant for your business.
So, what are you waiting for?
Streamline your record-keeping and NDIS compliance with ShiftCare today
ShiftCare is an easy-to-use care management platform designed to streamline day-to-day operations and reduce administration burdens for NDIS providers, as well as Aged Care and Disability Support services.
Boasting powerful and intuitive features, ShiftCare offers key solutions to improving care management, rostering, HR, invoicing, NDIS compliance and so much more, enabling you and your team to focus on delivering a higher standard of personalised client care.
So, if you’re looking for the best NDIS management software to help reduce the burden of compliance, ShiftCare has got you covered.
Book a demo or get in touch with our team today to discover how ShiftCare can revolutionise your care management and give you back more time for what truly matters.
[CM1]Link to May blog 1
