CD003: Easy Ways to Capture Information for your Progress Notes

This week, Carrie discusses ways to capture and record information that can be used later to create your client progress notes.

Remote coordinators often struggle for time with the competing demands of their job. They may be working with staff who are unable to complete documentation to the required standard. By applying some of these ideas you may be able to stop yourself from falling too far behind in writing your progress notes.

Tip 1. Keep a notebook in your vehicle. When staff drive around the community, ask them to make a note of any relevant details about clients. For example, clients who are away or reports from family members. Take the time each afternoon to write up the notes into the individual person’s progress notes. This method can also prompt you to follow up on any issues such as absent clients.

Tip 2. Keep a notebook at the Aged Care Centre to capture incidents and other observations. Check with staff before they finish for the day to clarify the information. This is also an opportunity to help staff learn how to write better notes.

Tip 3. Daily diaries can be used to log a lot of information, refer back to incidents, visitors, or remind you of essential tasks such as client re-assessment dates. This habit makes it easy to catch up on missing documentation.

Tip 4. Use your smart phone to capture pictures relevant to an incident or use the Notes App or voice recording App on the phone to capture a few notes. These can be transcribed to a client’s notes or you can upload to a client management system if your system allows this.

Whatever method you choose to gather the raw information, it is important to ensure you transfer relevant records to the individual client notes. Don’t leave it too long to do so as it will only make your job harder. Get into the habit of reviewing your daily notes and transfer them at the end of each day. It will make your life a lot easier!

You can read the original blog post here.