A shift note is a short written summary of what was completed during a service. It also records important information about how the client is doing and whether there are any concerns about their wellbeing or condition.
Why are shift notes important?
Shift notes are more than a compliance requirement. They provide a safety net for both the client and the support worker and help everyone involved in the client’s care respond promptly to concerns.
They also provide a record of the services delivered if there is a complaint, incident or dispute.
During an emergency, shift notes can provide important information to support immediate and appropriate care.
If there is a disagreement about when a worker arrived or what was completed during a service, clear shift notes provide a record of what occurred on that day.
Why are shift notes required?
The Department of Health, Disability and Ageing oversees Support at Home funding and requires providers to maintain appropriate records of the services delivered.
Regular observations from service providers help Local Guardians understand the client’s circumstances and identify and respond to changes. This allows care and support to be adjusted when needed and helps the client remain safe and independent at home.
Who needs to provide shift notes?
Any service delivered through the Support at Home program requires a shift note.
This includes:
- Support workers
- Personal care providers
- Cleaners
- Gardeners
- Allied health providers
- Other providers delivering funded services.
What should be included in a shift note?
A shift note should describe the support provided, or any support the client declined, and record the main activities and outcomes from the service.
It should include:
- The support worker’s name, where this is different from the provider’s business name
- The date of service
- The start and finish time
- A brief description of the tasks completed
- Any concerns about the client’s condition, including changes in behaviour, mood, appetite or mobility.
The information should confirm that the activities delivered match the services that were scheduled.
When should shift notes be entered?
Shift notes should be entered promptly so the details are accurate and any concerns can be responded to quickly.
Providers may use voice-to-text features on their mobile devices to record information before transferring it into Capital Guardians.
Shift notes must not be uploaded in bulk on a weekly or monthly basis. Delayed notes can prevent Local Guardians from acting quickly when an adverse event or important change occurs.
Can providers charge for entering shift notes?
No. Providers cannot charge an administration fee to the client’s Support at Home funding for entering shift notes.
Recording what occurred during a service is part of maintaining appropriate service records. Shift notes should be brief and focused and are not intended to be a full report.
Who can view shift notes?
Shift notes may be viewed by:
- The Local Guardians team responsible for managing the client’s Support at Home funding and approving invoices
- Local Guardians management and clinical staff when reviewing an incident, complaint or concern
- A legal or regulatory body where Local Guardians are required to disclose the information.
Shift notes must therefore be professional, objective, accurate and entered promptly.