As a service provider, Progress Note is an important document not only for ensuring the high standard of care for the patient but also to support the Provider Payment Assurance Program. So how does Comm.care help you quickly create high professional Progress Notes?
1. Introduction to Progress Notes
What are Progress Notes?
Progress notes are documents created by support workers at the end of a shift as proof of service delivery. Progress Notes constitute a legal record and are an essential part of the Client File. Sometimes these progress notes are known as case notes or support logs.
The purpose of progress notes is to record the support delivered on each shift or visit to update the status of your patients and their illnesses. Therefore, you, as a healthcare service provider, can track patients’ progress towards their goals.
Why is it so crucial for Healthcare service providers?
It is a part of records of support delivered that is required by the Provider Payment Assurance Program to get paid.
Information from progress notes can be used to write client NDIS progress reports to help NDIS review participant care plans and guide the carers whose work it is to implement participant goals.
Service providers use progress notes to share information between care teams and participant families to keep track of changes in patient status, routines and needs.
Progress Notes are compulsory to report incidents (and alleged incidents) to the NDIS Commission, either directly or via a supervisor, manager, specified person, or member of the provider’s key personnel.
2. How To Write Standard Progress Notes
Progress Notes can be handwritten or typed and should be recorded at the end of every shift. With Comm.care you can record Progress Notes easily and quickly access them.
To be effective, Progress Notes must be objective: you must report information that is measurable. Subjective documentation which reflects your opinions or assumptions is not recommended as it cannot be evaluated.
All Progress Notes must include necessary information as follow:
- Date and time of notes.
- participant’s name/participant’s reference number (previously NDIS number)
- Details of any reportable/significant incidents occurred, including those involving peers or others, and including details of witnesses if there are any.
Here are some guidelines to consider when making progress notes:
- Avoid abbreviations.
- If writing in the paper record, use blue or black ink; for errors, draw a line through the erroneous entry and initial.
- Rote cutting and pasting from previous notes without editing and updating is not permitted; using another provider’s observations or assessments is unethical and unprofessional.
- Write down events in the order in which they happened.
- Write concisely, accurately and include enough information that others can understand what happened.
3. How does Comm.care help you create high professional Progress Notes?
Easily record progress notes
With Comm.care, you can create a progress note for each participant in Circles. You just need to complete the fields within the Progress Note and make sure you complete these as a minimum so your Manager will love you! Other fields, depending on the service type (NDIS, or DSS) Comm.care will show you their related fields.
Quickly share and Collaborate with carers
Communicate better between care team members and never miss important updates by sharing notes and progress updates in Comm.care with just a few clicks.
Keep records of progress notes for audit purposes
You should maintain documentation of your supports, noting that supports can be shared across NDIS and non-NDIS funded participants. With Comm.care all records of progress notes are stored securely on our server, and there is no risk of information loss, theft or damage.