Best Practices for Keeping Care Notes Up to Date Using Home Care Software

Asha Neil

Written on 20 March, 2023
For healthcare providers, care notes are a valuable tool that facilitates exceptional care, alongside respect for patients’ rights and preferences. 

But if your team is working with outdated records, care notes can do more harm than good.

Keep reading as we break down how care notes fit into the delivery of high-quality health care services, along with tips for ensuring they’re useful and up to date.

Why Up-to-Date Care Notes Are Key to Quality Care

No matter how detailed a patient’s care plan is, there’s also a need for consistent documentation that details care delivery. That’s where care notes come into play.

Care notes form an essential part of a patient’s electronic health record. They give insights into a patient’s medical history as well as their progress. 

A well-written care note improves communication between care providers, and in doing so, enables a higher quality of care. With greater clinical data to lean on, your team will be able to make informed care decisions that lead to improved health outcomes.

This is particularly relevant for home health care, where your patients’ assigned health aides may not ever meet or even be able to communicate via email. Access to electronic health data ensures information-sharing, and as such, consistency in care plans and medical treatments. 

As clinical documentation, care notes also form a legal record that is permanently added to a client’s medical records. In case of incidents, they can be referred to and used to support any required investigations. They help protect your staff and your business, in addition to supporting an improved quality of care.

What Makes a Good Care Note?

Writing care notes is a skill that deserves honing which is why we’ve written a detailed guide to high-quality progress notes. As a brief summary, a good care note will include relevant information about a patient’s health and care delivery. This includes:

  • The names of the care providers

  • The time and date of the service delivery

  • Subjective and objective observations of a patient’s condition, e.g. clinical readings and patient-reported symptoms

  • Details of the care delivered, including precise clinical data where relevant

  • Changes in a patient’s health, care plan or general well-being

  • Any incidents that occur

With this information, care notes paint a detailed picture of a patient’s progress that can drive a better quality of care.

However, writing a high-quality care note isn’t just a question of what information you include. It’s also important to pay attention to style and tone. In particular, progress notes should be:

  • Written in a factual, professional and unemotional tone

  • Concisely written, without skipping essential details

  • In the active voice, e.g. “I administered the medication” instead of “the medication was administered,” so as to make clear who took each action

  • Reader-friendly for other healthcare professionals, without any abbreviations that aren’t widely understood

Want more insights into writing care notes? Check out our breakdown of nursing progress notes, complete with an example.

How to Help Your Team Keep Their Care Notes Up to Date

You can help your care providers write informative progress notes after every home visit by:

1. Providing Training

Training doesn’t have to be expensive or time-consuming to support your care providers in producing better quality progress notes. It just has to make your expectations clear. 

You can hold dedicated training sessions for team members. Alternatively, you can opt for more economical training in the form of documentation for your caregivers to refer to, as well as a video tutorial for aural learners. Follow up with personal feedback to support your care team in developing their clinical documentation skills.

2. Using Modern Tools

Moving to an electronic system will support your team in writing better care notes. Filling in and sharing handwritten notes isn’t just time-consuming, it also increases the risk of lost documentation, HIPAA breaches and illegible care notes. Perhaps most importantly of all, it makes quality control impossible. 

In contrast, electronic notes can be instantly written, uploaded and shared — and you can provide rapid feedback. For the most user-friendly experience, look for care management software with caregiver apps that allow your team to add progress notes on the go. Voice-to-text software can further support anyone who struggles to rapidly write progress notes with a keyboard, making your software more accessible.

3. Building Templates

There are lots of important details that need to be included in care notes. Help your team by creating progress note templates. They’ll reduce the risk of important clinical data being lost. With modern care management technology, you can even create different templates for various patient groups. 

Support Your Care Team in Writing Better Care Notes

Better quality care notes add up to a better quality of care. Your care providers will benefit from a stronger understanding of a patient's progress, which they can use to make better clinical decisions that improve care outcomes. Plus, having up-to-date care notes improves communication between caregivers, clients, and clients' loved ones.

ShiftCare’s care management software has rigorous care documentation management features. It will enable you to support your team through ensuring they have all the information required to provide an excellent quality of care. You can also create document and progress note templates to help your team include all relevant clinical data in their notes.

Your caregivers can use the ShiftCare mobile app, complete with voice-to-text technology, to record and share their progress notes on the go. And since the software is compliant with the Health Insurance Portability and Accountability Act (HIPAA), you can trust that protected patient information will be secure.

Plus, ShiftCare comes with a wide range of other essential care management features, including scheduling, electronic visit verification, accounting and payroll integrations and more.

Discover how easy clinical documentation can be, even when your team is working off-site. Try ShiftCare for free.

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