A Simple "How To"

1. Shift Notes in BaseCamp and sometimes in a client diary (few clients have a client diary)
2. Client Specific Feedback such as observation of health status Google forms and charts
3. Incidents and events that require escalating by immediate verbal report to HWH 1800 717 590, these include falls, injuries, medication errors, sudden changes in the clients health care condition and any WHS issues.

1. They can be read in a minute or two and are a timely and accurate record
2. The next shift has a quick snapshot of your shift and any follow-ups required
3. They provide important and clinical information visible to the Clinical Care Manager (CCM), the HWH team, and potentially the family members or interested stakeholders.
4. They help to create strong and sustainable working relationships in the workplace.
5. They are legal documentation and may be required for legal or insurance purposes.

1. Timely notes are best practice and expected; it is a good idea to post a shift note stating you have "arrived for your shift" and when you leave "I have finished my shift". 
2. Record one point to each sentence or paragraph, then press enter. This will make the notes more readable than just a mass of text.  
3. If you want to separate each sentence to a new line, select the '123' button on your keyboard (bottom left, it will take you to the next keyboard page) and then select the 'return' key (bottom right). Each sentence in your notes will stand alone and make it very clear to read.
4. If you need to write a paragraph, use easy-to-read, short, factual sentences and the process in step 3 above.
5. Use clear, accurate and objective language (no personal opinions) 
6. HWH expects a steady flow of daily shift notes for live-in shifts.  
7. Report on all tasks attended; some clients have food and fluid intake charts, or updates on food and fluid is required at regular intervals during the shift. Make your observation and send a quick update after each meal or drink.
8. Include information different from the usual daily routine, e.g. unusual events, changes in health condition, visitors, outings, appliance faults, safety or security issues. Some events require a specific form, such as an incident report.  
9. If domestic duties are required, check the domestic care list in the client's care instructions in Basecamp and undertake those tasks, then enter a shift note "all domestic tasks completed as per domestic care list". There is no need to list each domestic task, such as swept the floor, washing the dishes or wiped the kitchen benches.

• Arrived at Betty's apartment (your entry will be time stamped, so there is no need to state the time)
• Prepared her meal and provided support. 
• I assisted her in eating dinner by cutting up her meal and prompting her to use cutlery. 
• Betty usually does not need assistance to cut up her food, but this week, she has been needing my assistance. 
• Medications are given as prescribed (Rx) and signed (it is legally important to record this shift note immediately following medication assistance; again, it will be time-stamped). 
• After dinner, her daughter Kelly called, and they chatted for 15 minutes while completing domestic care. 
• Betty requested that I watch the news after dinner, so we sat together for about 15 minutes and chatted about news stories.
• At 7:30 pm, I physically assisted Betty with her walker to use the toilet, brush her teeth and put on her pyjamas. Several times, she stated it was difficult for her to undress and dress.
• Betty appeared disorientated and agitated on the way to bed and squeezed my arm. I spoke gently, smiled, and told her my name and that "she was safe with me." Then, I slowly guided her to bed.
• Once Betty was settled in bed, I left her to sleep and contacted the HWH on 1800 717 590 to verbally report and escalate the change in Betty's condition. 
• I was instructed to stay for half an hour longer to monitor her and ensure she was still asleep. At 8:30 p.m., I checked on Betty. She was still sleeping. I secured the apartment and left. 

• Medication signing sheets
• Personal hygiene questionnaire
• Bristol Stool chart
• Fluid chart
• Nutrition chart
• Weight chart
• Behaviours of distress chart
• Skin integrity chart (skin tears)
• Falls chart

• Acute health changes must be phoned into HWH when you notice something while on duty. Incidents to report are near-miss falls or actual falls, skin tears, sudden changes in health condition - dizziness, vertigo, behaviours of distress, security or safety issues, abuse or neglect, medication errors or WHS issues. This is known as escalating when you phone through the incident or event. 
• Escalating is a normal part of providing care and support and ensures the client's safety at all times. HWH will instruct you on what to do next; follow the instructions carefully and record the information in Basecamp. Complete any other documentation or forms as directed, such as incident reports. All forms are on BaseCamp Client file>Documents>Care Instructions>Reporting.
• A golden rule for knowing what to report is - if you ask yourself... should I report that? Then the answer is definitely YES ... the fact that you are thinking about the issue/event means it is worth mentioning to HWH. Always contact HWH on 1800 717 590 - 24/7 if you have any questions regarding issues/events while on duty or what to report. 
• Develop a healthy culture of notifying and reporting to strengthen client care and workplace relationships. This will build a high quality of service to the client and increase business referrals for HWH, thus creating more employment for you!

1. There is no need to write quotes such as "he said", "I said", or "she said." These unnecessary quotes distract the CCM and other support workers from important information in your notes. These statements could be discussed in a follow-up phone call to the CCM if they relate to an incident or event.
2. Avoid the temptation to "waffle on" in the shift notes; more notes do not make a better support worker. Instead, practice well-thought-out sentences or paragraphs that succinctly describe the care and support provided, noting any changes in the client's condition. 
   • For example, If the client has a treatment plan with many tasks that you initial against and these tasks are completed in 12-hour or live-in shifts, you could record all treatments and care provided as per the treatment plan, all domestic tasks completed as per domestic plan. 
   • Then continue to add updates or any changes in condition, unusual occurrences, incidents or events, outings and visitors as usual throughout your shift.
3. Refrain from being tempted to look at shift notes when you're not on shift; you also need the break from worrying about the client. 
   • Also, refrain from commenting on another support worker's shift notes, especially when you are not on shift or soon to be. The only exception to this is if you want to compliment someone's shift notes with a 'boost'. 
   • The CCMs or administrators can help you develop your shift note style to reflect HWH and industry standards.
4. Personal opinions are not required in shift notes. You can discuss opinions with the CCM if required. 
   • Opinions are subjective and not objective, i.e. if several people observed what occurred... would they write the same information? Sentences including client observations could start with these objective examples: it would appear... or I observed... or it seems that... 
   • Using this type of language is objective and professional. It protects the client's dignity and maintains the limits of your role.  
   • HWH or the CCM will read your notes and follow up with anything that requires further discussion, such as a decline in the client's physical or cognitive ability. 
   • Remember that family members may also have access to these notes, be respectful and professional in your comments.
   • Leave the medical or psychology opinions to other highly trained allied health professionals or the CCM. They are responsible for providing professional opinions and collaborating with the client, their family and the support workers to effect a change in personal care and support as the client's condition changes. 
   • If you give opinions, you may give the wrong one, and you could act above your role's limits. NB Recording personal opinions about an incident or event may have legal consequences, and it may influence how other support workers view the client. It could also be damaging to the client's self-esteem.