UPDATED SEPTEMBER 2023

Originally published 18/08/16 as '11 Tips for Writing Professional Progress Notes', this popular post has been updated to include additional information on writing progress notes in an electronic client information management system. 

So far in this series on documentation, we have looked at ways to capture information that should be documented and also when to document. This week we look at how to write professional client progress notes or documentation.

One of the common issues identified by auditors conducting quality reviews (or ourselves when completing a pre-audit review for an organisation) is poorly written client notes, or worse no regular notes at all. This post focuses on some of the issues that are relatively easy to address. Once care staff are aware of these basics we often see an immediate improvement in the standard of notes, so we suggest you share this post or the free ‘cheat sheet' that we can send directly to your inbox.

Client Progress Notes are Legal Documents

When writing progress notes, keep in mind that they are legal documents that can be brought before a court of law, so here are a few tips to ensure that your notes are acceptable and defensible.

Close up of a lady's hands writing in a notebook with the text: "writing better progress notes"

1. Are these the right person’s notes?

There is nothing worse than realising you have made an entry in the wrong person's notes. To avoid this make sure you have the correct ‘identifiers’ on the page before you start writing if you are using a paper-based system, or double-check you have clicked on the correct file if using an electronic system.

Identifiers are generally a person’s name and their date of birth. It may also be a code that is used to distinguish between individuals – this helps when you have two Mary Browns with similar dates of birth.

TIP: Never write notes on a blank sheet, even if the notes are contained within the person’s file; always ensure identifiers are noted on each individual page.

2. Use a blue or black pen (paper-based)

Blue and black pens are the colours of preference for legal documents as they photocopy well and are easier to read. So stick to either of these colours when writing your notes.

Avoid the use of red or other coloured pens as these are harder to read and do not photocopy well; although pretty, they are not considered acceptable colours for legal documents. Your written comments also need to be indelible – this means they cannot be erased – which means you also cannot use either pencils or erasable ink pens.

3. Write legibly (paper-based)

Your notes need to be clear and easy to read and decipher, after all, your co-workers need to be able to understand your notes. Poorly written, illegible notes can lead to medication errors and other adverse events for a resident or client. This is not the time to see how many words you can cram onto a single line; take the time to write neatly and in a size that is easy to read.

Printing your words rather than using cursive lettering is fine and, although it can look like you are shouting, it is okay to print in capital letters if this ensures your notes are legible.

4. Date of entry v date of event

Whilst most electronic client management systems will automatically add the date and time of your entry, if you are writing in paper-based notes make sure you add the date, and if it is standard practice in your organisation, the time of the entry.

Whilst notes should be written as soon as possible after an event or during or at the end of a shift sometimes ‘stuff happens'. If you are writing about something retrospectively, write the date of the entry at the start of the note as usual (for paper-based notes) and include the date and time of the event within the body of the note.

5. Sign your entry / Use the correct login

If you are using an electronic system your note will be entered against your login, this is why it is essential you are logged in under your name, double-check before you start writing and make sure you finish your entry and hit enter before getting distracted. Log out of the system before walking away.

For those using paper-based notes ensure you sign your entry. This may be a full signature or your initials – it will depend on your organisation’s policy. Make sure you sign directly after your last word to minimise the possibility of anyone adding additional notes after yours.

e.g. …took Mrs Smith to the clinic to pick up her medications.—B. Jones

6. Avoid blank space between entries (paper-based)

It might appear crowded, however, you should never leave blank lines or a space between entries. If you have a blank line that you don’t want to write on, draw a line through it, as this will avoid the possibility of someone inserting additional notes in the space.

Similarly, if you have accidentally started a new page and discover that the previous page still had white space, draw a ‘Z’ shaped line through the blank lines.

7. Make it clear where notes span more than one page or entry

If your note continues across more than one page you need to clearly indicate that the note continues, this is usually noted on both the first page and the continuing page.

Add ‘Note continues overleaf’ at the end of the page. At the beginning of the next page add the words ‘Continued from previous page’ before resuming your entry.

This practice ensures that anyone reading the entry understands that the information is spread over two pages and is less likely to miss any important details.

In an electronic system, you may need to reference a previous entry as part of a follow-up. In this instance make reference to the date and time of the first and any subsequent entries to make it easier for a colleague or auditor to follow the trail.

8. Errors happen

None of us are perfect, we all make mistakes. If you realise you have made an error in a paper-based note, simply place a line through the word.

Never use white out/Liquid Paper, or try to black out the entry with a felt pen or similar.

If you have made a note in the wrong person’s progress notes (see ‘identifiers’ in Point #1), simply rule a line through the entry and make a note that the information was written in the wrong client’s file by using the words ‘notes entered against incorrect client’. Remember to sign and date this!

For those using electronic systems, you won't be able to make a simple deletion, even where a system allows an administrator the authority to hide a note, this will remain in the system forever, this is to ensure important notes are not accidentally or maliciously removed.

If you make a mistake and have already hit enter, simply make a second entry referencing the first one, including the date and time, and note what the mistake was.

9. Use the correct words

Do not try to write complex words unless you are sure of their spelling and meaning. If you use a word incorrectly and your notes are subpoenaed due to an incident, it may appear that you or the organisation have taken an incorrect path of care. For example, the words anuresis and enuresis look and sound similar but they have opposite meanings:
anuresis – unable to urinate or lack of urine
enuresis – bedwetting

Even simple words can trip people up such as the words:
excess – too much of something
access – to gain entry

What about:
dysphagia – having difficulty in swallowing
dysphasia – the loss or difficulty in using or understanding speech

Remember that even many simple words that sound the same are spelt differently and have different meanings; plain and simple language is the best coarse course of action. Access to a dictionary (paper or online) can be one of your best friends.

10. Beware the acronym and abbreviation

An acronym is a word or name created out of the initial letters of words in a phrase, e.g. Commonwealth Home Support Programme = CHSP or ADL’s = Activities of Daily Living.

An abbreviation is a shorthand version of a word or phrase that may be used repeatedly, e.g. Mr = Mister (originally Master) or Mrs = Missus (or originally Mistress). 

It is always best to use the full word/s where possible rather than use an abbreviation or acronym, as this is less likely to lead to misinterpretation. However, if you do use a shortened version of a word or phrase, ensure that it is either a standard across the industry, with no chance of misinterpretation or is one approved by your organisation.

TIP: Many large health organisations have an approved list of abbreviations, with these being the only ones allowed when writing progress notes. Check with your supervisor or manager if you are unsure.

11. Keep your entry professional

Lastly, ensure that your entry does not contain assumptions, judgemental language or red flag terminology.

Just because a person looks glum does not mean they are sad. Just because someone is staggering does not mean they are drunk. Keep to known observations. State only what you heard, saw, smelt or felt.

Joe felt hot to the touch – not Joe has a fever (maybe he has been sitting out in the sun all day);

Billy was observed to be unsteady on his feet – not Billy was drunk because he was staggering around (Billy may be exhibiting signs of a neurodegenerative condition such as Machado Joseph Disease – MJD);

Sarah smelt strongly of urine – not Sarah was incontinent (Sarah may have been sleeping on a mattress that was urinated on by someone else).

When you state that Trixie was being offensive or obstructive, you are making a judgement call on her behaviour – Trixie’s behaviour might offend you, however, her intent might be otherwise. If you merely state the actions that Trixie has taken and your response to them, you are maintaining professional neutrality.

Red flag terms describe words or phrases that can lead to sensationalism. These could be describing a person as being the ‘victim' of domestic abuse or there is an ‘epidemic' of scabies within the household.

Just remember, stick to the facts and only the facts.

And if you want to take your progress note writing to the next level why not check out our comprehensive online course* where Kellie and I step you through the process of professional note writing. Not only will you be protecting your residents /clients, but you'll also be improving your professional standing.

*Face-to-face training can also be arranged for organisations who would like us to come out and upskill their team, send us your request to info@cdcs.com.au.

BONUS TIP. Close the loop

One additional bonus tip. This is something that I have seen auditors pick up time and time again (it's so common that they seem to go looking for it). Not closing the loop. 

What am I referring to? Well, let's take an example.

A client or resident goes to the hospital, this is rightly noted in the person's progress or client/resident notes. However, the following entry relates to the person attending a social outing or event. What happened in between?

What the auditors and your colleagues are looking for is continuity of information. When the person came home what was their health status, did they require additional services, did they need to be reassessed for higher care support, what changes did you make, if any, to their care plan. Please, close the loop.

This post is Part 3 of our four-part series on client documentation – check out our other posts now:

Part 1: 4 Ways to Make Client Documentation Easier
Part 2: Progress Notes – what should you document?
Part 4: Correct Storage of Client Documentation – For Your Eyes Only!

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Carrie

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