Writing progress notes that are useful the next day
By Autonomy Care team. Published . 4 minute read.
A useful progress note says what support was given, how the participant responded, anything that changed or worried you, and what the next worker needs to know. Write it before you leave the shift, in plain words, with facts rather than opinions, and link it to the participant's goals where you can.
A progress note is written for the next person who reads it: the worker on the next shift, the coordinator, or the participant and their family. If they can act on it, it has done its job.
What to include
- The supports you gave, and when.
- How the participant responded, in their words where possible.
- Anything that changed, worried you or needs follow-up.
- Progress towards the participant's goals.
What to leave out
Opinions about the person, guesses about causes, and details about other participants. If something needs reporting as an incident, report it as an incident as well as noting it. See the glossary entry for SIL for terms used in shared living.
In Autonomy Care
Progress notes
Shift notes written on shift and read the same day.
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