How to write progress notes on Shiftcare?

In the rapidly evolving landscape of healthcare and support services, technological advancements continue to revolutionize the way we deliver care. In the National Disability Insurance Scheme (NDIS) industry, where personalized support is paramount, tools like the Shiftcare app are invaluable. Let’s delve into how this app simplifies progress notes recording, catering to both caregivers and individuals receiving support.

Shift Start and Finish Time:
This simply refers to the time you start and end your shift, for example, 9:00 am to 05:30 pm.
Example: Caregiver arrives at 9:00 am and finishes at 05:30 pm.

Record any observations or changes in the individual’s health during your shift. This could include noting symptoms, medication administration, or any health-related concerns.
Example: Noting that the individual’s blood pressure was slightly elevated during the morning medication routine, or observing signs of fatigue due to recent changes in medication dosage.

Definition: Document the meals provided to the individual or any special dietary requirements they may have. Also, note any eating habits or preferences observed during the shift.
Example: Documenting that the individual requires a pureed diet due to swallowing difficulties and noting their enjoyment of today’s lunch, which consisted of mashed potatoes and soft-cooked vegetables.

Definition: If you’re responsible for transporting the individual, record the distance traveled for reimbursement purposes. This could include trips for medical appointments or community outings.
Example: Recording the distance traveled to take the individual to a physiotherapy appointment or to attend a community event, ensuring accurate reimbursement for travel expenses.

Definition: Document any behaviors exhibited by the individual during the shift, both positive and negative. Include any triggers or interventions used to manage behaviors.
Example: Documenting that the individual exhibited signs of discomfort during a transfer from the bed to the wheelchair, prompting the caregiver to adjust the transfer technique to ensure comfort and safety.

Definition: Note progress towards the individual’s goals as outlined in their NDIS plan. This could include achievements, challenges faced, or adjustments needed to support goal attainment.
Example: Noting progress towards the goal of increasing independence in self-care tasks, such as successfully assisting the individual in brushing their teeth without as much assistance as before.

Definition: If any incidents occur during the shift, such as accidents, injuries, or conflicts, provide a detailed description of what happened and any actions taken in response.
Example: Describing an incident where the individual slipped while transferring to the bathroom, resulting in a minor bruise. Detailing the actions taken, such as applying first aid and reviewing transfer techniques to prevent future occurrences.

Definition: Record any assistance provided with personal hygiene tasks such as bathing, grooming, or toileting. Note any issues or concerns related to hygiene.
Example: Recording assistance provided with bathing, including using specialized equipment such as a shower chair and noting any skin irritations or areas of concern.

Definition: Document any tasks related to maintaining a clean and safe environment for the individual, such as cleaning, organizing, or household chores.
Example: Documenting tasks such as vacuuming and tidying up the living room to ensure a safe and clutter-free environment for the individual to navigate in their wheelchair.

Definition: Describe any social interactions or activities engaged in during the shift. This could include outings, visits from friends or family, or participation in group activities.
Example: Describing a visit from the individual’s family members, noting the joy and engagement experienced during the interaction, or documenting participation in a virtual social group activity organized by the support service.

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