What’s a shift note?
A shift note is a short written summary, describing what was done during a shift. It also notes anything important about how the recipient is doing or if there are any concerns about wellbeing or condition.
Why are shift notes important?
Shift notes serve as more than just a compliance requirement. They act as a safety net for both the client and support worker, fostering collaboration among support workers to address concerns promptly, averting potential serious situations.
They are a record of services provided in case of a complaint, incident or dispute.
During emergencies, they become invaluable, providing critical information for immediate and necessary care.
Should there be a discrepancy around the arrival to a shift or the work completed, well-maintained shift notes act as a record confirming the services rendered on that particular day. This serves as a reliable reference, clarifying any uncertainties about the services provided.
Why are shift notes required?
The Department of Health and Aged Care oversees Support at Home funding and has set criteria to ensure the continuation of these services, including the mandatory recording of shift notes.
The regular observations by those providing services, help the Support at Home provider to better understand the client’s situation and are pivotal in detecting and responding to changes. This proactive approach assists care providers in adjusting support, which improves the recipient’s ability to maintain a safe and independent lifestyle at home for an extended period.
For more information of department requirements, you can refer to sections 3(d) and 3(e)Standard 3 of the Aged Care Quality Standards.
What is typically included in shift notes?
Typically, a shift note will include details of the support provided (or rejected), highlighting key activities and outcomes achieved during the shift. This validates that the activities delivered align with the specific services that were scheduled.
The following items should be included in a shift note:
-Name of the support worker (if this isn’t the same as the company name)
-Date of service
-Start and finish time
-Brief description of tasks completed
-Any concerns about the client’s condition, such as a change in behaviour, mood, appetite or mobility
When should shift notes be entered?
Shift notes should be entered promptly to ensure accurate recollection of events and timely responses.
Voice-to-text features on mobile devices can be used to capture notes before they are transferred into Capital Guardians.
Bulk uploads of shift notes on a weekly or monthly basis are not permitted, as delays can hinder quick action in response to adverse events and lead to serious consequences.
Can I charge the Support at Home funding for entering shift notes?
Charging an admin fee for inputting shift notes isn’t permissible through the Support at Home funding. Documenting shift notes is a common practice across various industries, be it healthcare, trades, or beauty services. Maintaining a record of events is crucial for optimal client outcomes and conflict prevention.
Keeping shift notes concise and focused is key. It is not intended to be a full report.
Who will be able to view shift notes?
The following people have access to client shift notes. It is therefore essential that they are professional, objective, timely and accurate.
– The Local Guardians team who are managing the Support at Home funding account and approving invoices.
– The Local Guardians management and clinical team if reviewing an incident, complaint or concern.
– In some circumstances, Local Guardians may be legally obligated to disclose your shift notes to a legal or regulatory body.