You are expected to complete a daily visit note to keep the allocated care coordinator and the care recipient's family updated. Please check-in to your visit at 8 am and check out the next day at 8 am - providing notes, client wellbeing scores, incident reports and confirmation of two-hour breaks. Each note must reflect a 24 hours period and if you are experiencing any technical difficulties in logging in/out at 8am, please contact the office for support.
It is critical to our professional carers and care recipients' well-being that this is completed without fail. Our office team works on this information to ensure everything is safe and secure. If you do not complete your note we will have no choice but to enforce our disciplinary policy and procedure.
Do’s
Factual
If you feel it’s useful to include your own opinions on the record, ensure they are based on professional judgements backed by experience or evidence.
Objective
Avoid including unnecessary details when taking care notes. The priority is the client and their well-being, so it’s important to be objective and to not include any emotionally charged language. It’s best to keep to the facts and to note down the most relevant information.
Professional
No matter how friendly you get, always take a professional and formal approach to note writing.
Events during the day
Include clear timings of the break time each day
Tasks during the day
Record the notes of all events and tasks as soon as possible so the details stay fresh in your mind.
Ensure consent and choice are clearly documented
Use key words like: 'asked' / 'checked' / 'discussed' / 'chose' / 'chose to' / 'wanted' / 'asked for' / 'agreed' / 'consented' / 'options' / 'choices' /
Nutrition and hydration
Please provide clear details of the food/drinks offered and what food/drink was accepted and consumed
Notes must clearly present a balanced diet throughout the week and acceptable fluid intake
Don'ts
Complaints
Personal feelings
Don’t include opinions based on personal feelings, hunches or assumptions.
Here is a recommended format for daily notes to be written throughout the day.
Please make sure you read the full example here:
The portal allows you to sign in at 8am and start taking notes throughout the day. The notes will save as you type them and you can go back and add notes as the day goes by. Please take notes as the events of the day unfold, to ensure you do not forget all the important details that must be recorded.
16.11.23 8 am | Mrs Jones woke up around 8am and called me. I went into her bedroom and asked if she had a good night. Mrs Jones said she had a good rest, looking forward to start the day. I assisted Mrs Jones to have a shower, she was able to wash the upper part of her body but needed my support with her legs and her back. We discussed about what Mrs Jones would like to wear and she chose to have a skirt and her yellow jumper. We then went to the lounge and Mrs Jones was able to walk with her zimmer frame, monitored by walking beside her. I asked Mrs Jones what she would like to have for breakfast she wanted scrambled eggs with buttered toast and a glass of juice. Mrs Jones ate all her breakfast: 2 scrambled eggs with 2 pieces of toast with butter and had half a glass of orange juice.
After breakfast, I asked Mrs Jones if she would like to have her medication and she agreed, asking for a glass of water for that. I checked the meds against the MAR Sheet and gave all the tablets in an egg cup that Mrs Jones uses to have her medication.
After Mrs Jones had her medication, I took the egg cup and empty glass back to the kitchen and signed the MAR Sheet to confirm the medication has been taken. Mrs Jones then asked for a cup of coffee and asked me to join her so I had a cup of tea with her and we made a plan for the day. We also discussed about meal options for lunch and dinner. |
11am | Around 11am the neighbour stopped by for about 30 minutes and had a cup of tea with Mrs Jones. Meanwhile, I prepared the lunch. As discussed, I made tomato soup and served that with two slices of buttered bread at 12.30. I asked Mrs Jones if she would like her lunchtime medication and she agreed. I checked the meds against the |
1.30pm | would like her lunchtime medication and she agreed. I checked the meds against the MAR Sheet and put all the tablets in the egg cup for her. I asked Mrs Jones if she would like water or juice for her tablets – she wanted water. Mrs Jones wanted to stay in and watch TV until about 5pm. |
2pm | I then went to the kitchen and after double checking I signed the MAR Sheet correctly, I cleaned the kitchen and then did som |
5pm | Mrs Jones had a minor fall when going to the bathroom as she lost her balance and I supported her down to the floor. After a few minutes, Mrs Jones said she feels fine. And would like to get up. I offered her a chair for support, put the chair next to her Mrs Jones managed to get herself up slowly by holding onto the chair. I called the ON-Call to report the fall and completed an Incident Report Form in the folder. After making sure that Mrs Jones is safe back in her armchair, I went to the kitchen to prepare dinner. As discussed in the morning with Mrs Jones, I prepared garlic and herb chicken with mashed potatoes and vegetables. Mrs Jones ate all her dinner and had a cup of tea after that. |
7pm | After dinner, I asked Mrs Jones if she wants to stay in the lounge longer but she said she feels quite tired and would like to go to bed. I assisted Mrs Jones to her bedroom and asked her if she would like to have her nightie or pyjamas – she chose to have her nightie. Mrs Jones was able to change with minimal support. |
8.30pm | I then asked Mrs Jones if she would like her evening medication and she Agreed. I checked the meds against the MAR Sheet and put all the tablets in the egg cup as usually and took that to her bedroom. I asked Mrs Jones what drink would she like for her tablets and she asked for water so I got her a glass of water. Mrs Jones took her tablets and had half a glass of water. |
9.00pm | I made sure she is comfortable and has a drink of choice (glass of juice) on the bedside table before saying goodnight. I then took the egg cup into the kitchen, signed the MAR Sheet to confirm the medication has been taken. Cleaned the kitchen |
9.30pm | Washed all up and put away for next day and after I made sure all doors are locked, I went to bed. |
17.11.23 |
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8.30am | Mrs Jones called me when she woke up. I went in the bedroom, greeted and asked how the night was and she said she slept really well and feels rested. Mrs Jones didn’t want to have a shower but preferred a bed bath so I assisted with the tasks that she couldn’t complete herself, like her back and legs. Mrs Jones asked me to put some cream on her heels.
Applied the cream and asked Mrs Jones if she likes her socks on that she did want them on. We discussed about what Mrs Jones would like to wear and she chose to have a skirt and her dark blue cashmere jumper. We then went to the lounge and Mrs Jones was able to walk with her zimmer frame, monitored by walking beside her.
I asked Mrs Jones what she would like to have for breakfast she wanted rice crispies with milk. Mrs Jones ate all her breakfast and then had a cup of tea. |
9.30am | After breakfast, I asked Mrs Jones if she would like to have her medication and she agreed, asking for a glass of juice for that. I checked the meds against the MAR Sheet and gave all the tablets in an egg cup that Mrs Jones uses to have her medication.
After Mrs Jones had her medication, I took the egg cup and empty glass back to the kitchen and signed the MAR Sheet to confirm the medication has been taken. Mrs Jones had an appointment booked for 3pm to see her GP for a routine check so I asked if she would like me to do her hair and make-up and she was really excited about that.
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10am | I did Mrs Jones’s hair as she wanted and then she told me how she likes her make-up so I did that for her and she was really happy with the results. Mrs Jones then wanted to visit her neighbour Rose for a coffee. Mrs Jones was able to walk to the door using her zimmer frame while I monitored walking beside her. Mrs Jones then wanted to use the wheelchair for us to go across the street, to Rose. |