Basics To Writing Shift Notes.
Writing shift notes doesn't have to be confusing; read through this quick guide on the basics of shift note writing.
Disclaimer Notice:
This blog is only meant to serve as a general reference. Please consult your company policies, https://www.ndis.gov.au/ or your respective state or federal laws for official information.
Shift notes are a chronological record of interactions, observations and actions involving a specific person and must be completed before the end of your shift. All activities on shift should be geared towards the various domain goals within an individual's Care Plan. Therefore the shift note is a living document and is continually updated to capture achievements, progress and areas of concern.
Why keep shift notes?
- We keep shift notes for accountability
- legal responsibilities
- a history of the person's successes and areas they may need help.
What to include in your shift note?
Shift notes should be impartial and accurate. They should not include derogatory or emotive language, and subjective opinions should qualify with relevant background information. Shift notes should be;
- non-judgemental,
- should avoid making assumptions,
- should always indicate clearly when a comment is an observation,
- should be made clear when you are recording the person's own words.
Shift notes with a care plan.
Each person's goals are stated in their care plan and identify areas of need that we can support the person to achieve.
Always remember
- who
- what
- why
- when
- where
- how
Please always refer to your companies policies when creating shift notes.
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