Why Care Notes Are Key to Quality Care

Care notes play an essential role in providing home care services. As a medical and legal document, they serve as a record of a patient's health and well-being, along with the care they receive.

Your staff can review past care notes to get a better insight into a client's current condition and needs. With this information at hand, your team of caregivers is better able to make healthcare-related decisions, such as whether to administer medicine or refer the client for specialist treatment.

You can use care notes to understand a client's evolving care needs. Whether you're tracking their progress toward a goal or evaluating if there are signs of new conditions, such as dementia, progress notes help you build a picture of a client's health and well-being.

What Makes a Great Care Note?

Care notes should be objective, factual records. They need to strike a balance between containing all the relevant medical information and being concise enough that other staff members can quickly read and understand them.

When writing care notes, your team should:

• Be as specific as possible

• Use neutral language

• Adopt the active voice, i.e. start sentences with the person doing the action

• Avoid jargon and acronyms that may not be widely understood

Care Notes Examples

There's nothing like an example to help demonstrate what makes care notes useful. Let's break down some good and bad examples.

Example 1: Specific vs Vague Language

Look at the difference between these two care notes:

Vague: "Ahmed has a fever."

Specific: "Ahmed had a temperature of 101.5°F at 10:25 am."

Both are accurate, but the second is more useful. If a different caregiver then took Ahmed's temperature at 3 pm, they would know if his fever was improving or getting worse.

Example 2: Passive vs Active Voice

Active voice always makes it clear who did a given action.

Passive voice: "Acetaminophen was administered to Gloria."

Active voice: "I administered acetaminophen to Gloria."

In the first example, it’s not clear if Gloria received the medication from her caregiver, a family member, or a different medical professional. Using the active voice assigns responsibility and removes confusion. 

Example 3: Neutral vs Loaded Descriptions

Neutral language is more professional, plus it's often more accurate. Take these two examples:

Loaded language: "I tried to give Jenny her medication, but she was uncooperative."

Neutral language: "Jenny refused to take her medication."

The first paints Jenny as a troublesome patient, while the second sticks to the facts. 

How to Help Your Team Write Care Notes in 3 Steps

You can't compromise on the quality of your care notes. However, more time spent on paperwork means less time spent providing care services.

Fortunately, you can help your team write care notes quicker and better than ever with our tips. They'll support your team in producing concise, detailed records in minutes.

#1 Opt for Electronic Care Notes

Electronic care notes provide a better record. They are less likely to be lost or damaged, you can instantly share them with other caregivers, and they are easier to quickly search and review.

What's more, writing and uploading digital care notes is simple. Ideally, your care team will be able to add care notes via their mobile app, so they can do it while still in the patient's home.

Modern technology such as voice-to-text will help your caregivers quickly add new notes even if they have their hands full or they're a slow texter. Autocorrect and predictive text can also help make your caregivers' lives easier.

Key Tip for Electronic Progress Notes

Use a cloud-based document management system for your progress notes. You'll still be able to instantly share them, plus it can be more secure than using emails.

#2 Use Care Note Templates

Templates can be an immense help as your team writes care notes. They'll ensure your caregivers don't leave valuable information out. Plus, they'll reduce the time your team spends thinking about what to include.

Key Tip for Care Note Templates

Create separate care note templates for different client groups. This way, you'll be able to make sure that all relevant information is tracked, without creating overly long documentation. We also recommend adding individual client goals to the care note templates.

#3 Provide Training on How to Write a Care Note

The right training will support your team in confidently and efficiently filling in care notes. You'll be able to boost quality while also reducing the time your team spends on record-keeping.

Training doesn't have to be time-consuming. You can create a 10-minute video, a training quiz, or even a PowerPoint presentation.

Key Tip for Training

Supplement the training with support from leadership. Ask managers to periodically message caregivers via your home care software with both positive and constructive feedback.

Care Notes Made Easy

When it comes to recording high-quality care notes, home health software can be your secret weapon.

ShiftCare's HIPAA-compliant home care software is built with home health care agencies' needs in mind. Your care team can use the mobile caregiver app to add progress notes on the go. With voice-to-text features, they can even update a patient’s vital signs while measuring them. And you can create document templates for different patient groups, ensuring that the most important information is never left out.

Plus, ShiftCare comes with a wide range of other essential features, such as rostering, time-tracking, electronic visit verification, and billing.

Discover how easy care notes can be. Try ShiftCare for free.