Daily notes in social care

Daily care notes are a vital aspect of social care. They provide a record of day-to-day care and the activities, events and interactions that take place. Accurate and well-maintained notes are critical for ensuring the wellbeing of those receiving social care services. Not only do these notes help to identify any potential changes in the individual’s condition or behaviour but they also assist with ensuring the quality of services provided.

This blog will look at why daily notes are important, some examples and tips for writing effective notes.

Why are daily care notes records important?

Daily notes have different purposes depending on who is reading them. There are several reasons why daily notes are looked at. So, it’s essential that the information being entered is accurate and contains a good level of detail. Besides being a legal requirement and a professional necessity, the main function is to support and evidence the level of care being provided.

Notes are important tools for care staff because they contain facts and professional observations. The details within a care note act as evidence to make decisions and identify issues that require attention. They can also be used to communicate with other healthcare services to promote continuity of care. Ultimately, they are necessary to ensure people receive a good quality of life.

Managers and inspectors can audit notes to check if certain standards of service are being provided. This is done to protect both the residents and the business. Family members or close friends of residents may also wish to read notes to understand how the individual is coping in certain situations and to get peace of mind.

In the event of an internal complaint or court case relating to a resident’s healthcare, notes will be used as key evidence in the investigation. If inaccuracies or missing information are found to have contributed to mistreatment or harm, the staff member who recorded the note can be held accountable.

How to write daily care notes in care homes

On the surface, there are five main components to a daily care note:

• The time and date
• The event type
• The resident’s name
• The written note
• The name of the person recording the event

This structure may look straightforward but it’s ‘how’ the note is written that will determine the quality. For best results when writing notes, attention to detail and thoroughness are paramount. Notes also shouldn’t contain typos or feel rushed. This doesn’t mean they have to be lengthy – they should be concise and only include relevant details.

The person you are creating the note for should feel included in the process where possible. It’s important that they are happy with what is being written. They might be able to offer suggestions that expand on your description of events, which could be the key piece of information that helps someone else later on.

Below are three examples of one daily note event with an analysis underneath to demonstrate how different levels of detail can change how people perceive the note.

Poor sample daily note

“Christina went to bed early, not feeling well. Gave her something to settle stomach. Will check on her later.”

There isn’t any detail in this example and it feels rushed. It doesn’t give you much context around the event and doesn’t display much concern. There’s no time, date or staff name. It raises the following questions: What time did this happen? What’s wrong with Christina? How bad was she feeling? What exactly was she given? Who recorded this note? What time will the staff member be back to check on her?

Acceptable sample daily note

Bedtime: 20:15, 20/01/2023

“Christina wasn’t feeling well after dinner. She said her stomach hurt and wanted to lie down so I brought her room and put her to bed. She was given a small dosage of Imodium to help settle her stomach. Will check on her in two hours.”

– Melissa Chaplin

In this example, we can see the event occurred quite early in the evening. The time acts as a reference for the next check-up and we know the staff member Melissa should be carrying out a check at 22:15. There is a sufficient amount of detail in regard to the chain of events and we know what medication was given. However, more questions remain.

Good sample daily note

Bedtime: 20:15, 20/01/2023

“Christina wasn’t feeling well after dinner. She ate lasagne with a slice of buttered bread. Shortly after, she said her stomach hurt and wanted to lie down so I brought her room and put her to bed. She doesn’t normally eat bread because of an intolerance to gluten. She doesn’t think it’s anything serious but she took 1 Imodium Dual Action Relief tablet to help settle her stomach. Will check on her in two hours.”

– Melissa Chaplin

This example goes a step further by explaining what may have caused the stomach issue. There is some historic information regarding gluten intolerance and eating habits, which helps ease the reader in knowing what’s happened probably isn’t too serious. It shows Melissa has a good knowledge of the resident and handled the situation competently. A staff member reading this on the next shift will know exactly what medication Christina took in case the stomach issue isn’t resolved.

Tips for recording daily notes

An effective daily note is one that provides sufficient and meaningful information that other people can use to support them in their roles. A well-written note should aim to safeguard the resident. However, demonstrating good levels of competency and care will help protect the staff member as well. Following these tips can help produce top-quality records:

Write person-centred care records

Person-centred care means putting the resident at the heart of the service. Everything should be done with their best interests in mind. This includes the way records are written. They should focus on the needs of the resident and contain respectful language. Sharing your finished note with the individual is an effective way to ensure it reflects the thoughts and feelings of the resident.

Don’t delay recording

Record the note as soon as possible so the details stay fresh in your mind. Ideally, you would do this while in the company of the resident so they can read it and feel included. This is called point of care recording. The longer you wait, the more chance there is that important details might be forgotten which could eventually end up causing harm to the resident.

Introducing care software like CareDocs into your care home is one solution to more efficient care recording. CareDocs comes with a comprehensive mobile care recording platform (CareDocs Cloud Portal), which staff can use on mobile phones and tablets to log care notes directly into a shared digital system.

Be precise but compassionate

When it comes to accuracy and detail, holding back doesn’t benefit anyone. However, it’s important to keep in mind that lots of different people will potentially read the note, including the individual whom it’s for and their family. In some cases – for example, when describing an individual who has poor personal hygiene – it might be tricky to find the right words to describe the scene without sounding insensitive.

Try to find a middle ground that gets your point across without risking upsetting anyone. Be constructive and explain why things are the way they are. E.g., what has led to poor hygiene and what is being done about it? The record may take longer to formulate but it will help maintain dignity and respect.

Keep it professional

It’s easy to develop close friendships with the people in your care. Relationship building is a fantastic skill and a rewarding aspect of the job. No matter how friendly you get, always take a professional and formal approach to note writing.

Focus on the facts

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. Don’t include opinions based on personal feelings, hunches or assumptions.

To help separate opinion from fact, professional opinions should be clearly labelled with solid reasoning to explain how you came to that conclusion. Include observations and analysis of evidence to display a clear thought process. This will help others understand your perspective.

Avoid jargon and abbreviations

People who read your notes – either to provide care or to audit records – may not know the meanings of certain special words, expressions or abbreviations. Misunderstandings can lead to mistakes or delays and end up working against you. It’s always best to aim for clarity.

Check older notes to help you better understand a situation

Reading historic records can help you become familiar with a resident’s healthcare journey and support you in making new professional judgements. You don’t always have to comply with past decisions if you deduce better ways to do things. But if you do go in a different direction then you should explain your reasoning and use evidence from previous notes to demonstrate due diligence.

Using CareDocs

CareDocs is a digital care management system that gives care homes access to a wide range of person-centred tools. One popular system feature is the ability to create Daily Notes. You can quickly add notes by logging on to a computer or via a smartphone or tablet at the point of care.

When it’s time to record a note, you can select defined event types from a list to help keep your records consistent. To help make the recording process as swift as possible, CareDocs automatically inputs the current time and date of note creation, as well as the staff member’s name.

This means all you need to focus on is writing the note itself.  However, you are able to log emotional responses at the same time which are recorded against the event type for reporting purposes. When you save a digital note it automatically gets stored in the shared system.

Finding notes for care, audit or inspection purposes only takes a few moments. Our search filters allow you to locate historic notes by event type and date. Digital reports can be generated instantly using daily note information. For example, staff can pull together a brief summary of recent events to assist a handover, a detailed summary of what happened during specific events and emotional responses to events.

For more information about how CareDocs can support your care home and increase efficiency, call us on 0330 056 3333, email us at sales@caredocs.co.uk or book a free demo.

Sources

CQC – https://www.cqc.org.uk/guidance-providers/adult-social-care/what-good-looks-digital-records-adult-social-care

SCIE – https://www.scie.org.uk/care-providers/recording

Looking for more info about using digital daily care notes? Here’s another blog you might find useful: 

What’s digital care recording like in CareDocs?