Practice
Writing better daily care notes: a practical guide for support workers
Pelp Care · · 6 min read
Daily care notes are one of the most important records in social care. They help the next person on shift understand what has happened, show how an Individual is being supported and build up a picture over time that managers, families and inspectors may rely on.
Good notes do not need to be long. They need to be clear, factual and focused on the person. This guide covers the habits that make the biggest difference.
Write about the person, not just the tasks
A note that only lists tasks, such as “personal care given, lunch eaten, medication administered”, tells the reader very little about how the Individual actually was. Person-centred notes describe their mood, what they chose to do, what they enjoyed and anything that seemed different from usual.
Use the Individual’s preferred name and, where it helps, record what they said in their own words.
Stick to facts and describe what you observed
Record what you saw and heard rather than your interpretation of it. “Sam was difficult this morning” is an opinion. “Sam declined breakfast twice and said he did not want to go to the day centre” is an observation that the next person can use.
If you do add your view, make it clear that it is your view and explain what led you to it.
Record changes, however small
Changes in eating, sleeping, mood, mobility or behaviour can be early signs that something needs attention. One small change on its own may not seem important, but several small changes recorded by different people can reveal a pattern.
If something seems different from usual, write it down, even if you are not sure it matters.
Write notes as soon as you can
Details fade quickly, especially across a busy shift. Recording as close to the event as possible makes notes more accurate and means the next person has up-to-date information. If you have to record later, note the time the event actually happened.
Keep it clear for the next reader
Your notes may be read by colleagues, managers, families, social workers or inspectors. Write in plain English and avoid abbreviations that others may not understand.
- Who: which Individual, and who else was involved
- What: what happened, what you observed and what was said
- When: the time of the event
- What you did: the support you gave and any actions taken
- What next: anything the next shift needs to know or follow up
Common mistakes to avoid
Most weak notes are not wrong, they are simply too vague to be useful.
- Vague phrases such as “good day” or “settled” with no detail
- Judgemental language or labels
- Copying the previous day’s note
- Leaving out incidents or concerns because they seemed minor
- Recording information about other Individuals in someone’s notes
How technology can help
Digital care notes can make recording faster, particularly when staff can speak or type in their own words and tidy the note afterwards. Pelp is being designed to support this, while keeping the support worker responsible for checking that the final note is accurate before it is saved.
Whatever system you use, the principles in this guide stay the same: write about the person, describe what you observed and make it useful for whoever reads it next.