NDIS progress notes are essential documents that allow caregivers and service providers to keep track of their participant's progress and evaluate ongoing support. In this article, we'll dive into the best practices and common mistakes when writing progress notes, as well as some progress note examples. Before we do, let's explore why NDIS progress notes matter so much in giving the best care for your participants.
NDIS Progress Notes Brief Introduction.
NDIS Progress notes are used to record the participant's journey, and progress, as well as any changes in their situation or condition. With progress notes, service providers can keep track of your NDIS participant's physical, emotional and mental health progress, as well as their social interactions and their capacity for independent living.
Why is NDIS Progress Notes Important?
NDIS progress notes are critical for several reasons.
- Enhance Communication: NDIS progress notes are an effective way for the service to communicate with participants and their loved ones. It plays a crucial role in ensuring everyone involved in a participant's care is aware of their current status and progress.
- Enable Accountability: Progress notes are essential for demonstrating that the services that are billed to the NDIS are being delivered and are helping the participant achieve their goals.
- Facilitate Continuous Improvement: By documenting a participant's journey, progress notes can highlight what's working well and what isn't; as a result, the service providers can stay informed and adjust future care to ensure the best result for the participant.
- Support Auditing: If the NDIA audits a participant's plan, progress notes will provide a necessary document for the NDIA to review the participant's progress and the services provided.
- Dispute Resolution: Disputes may arise in various scenarios during the NDIS care process. They could be between a participant and a service provider, or between different service providers. In case of any dispute regarding service provision, NDIS progress notes are a reliable record, helping to address and resolve the issue.
Four Different Types of NDIS Progress Notes.
The NDIS progress notes can be split into four types which are group services, personal services, NDIS transport and short-term accommodation. Let's dive into exploring each type of progress note to understand the differences between them.
1. NDIS Group Services
NDIS group service is the type of NDIS support that is delivered in a group setting. For example, a group therapy session, social activities, or community events. As a result, NDIS progress notes for group services should outline not only the events but also participants' interaction and engagement.
The NDIS progress notes for group services might include the activity, participant's interaction, NDIS goal, and their progress toward those goals. It's also important to note any challenges, or social improvements during the session.
2. NDIS Personal Services
NDIS personal services refer to one-on-one support provided to an NDIS participant. For example, individual therapy sessions, life skill support, or any other services delivered on a personal level.
NDIS progress notes for personal services should be in-depth and personalised. They usually include what services were provided, the participant's responses, the progress toward their NDIS goals, and any changes in their condition.
3. NDIS Activity Based Transport Services
NDIS activity based transport service is a unique NDIS support, which is designed to help NDIS participants travel to their desired destinations that are crucial for their social and personal well-being. Unlike other forms of support, NDIS transport services are not about what happens within a session, but rather the journey itself - getting from point A to point B safely and comfortably.
As a result, NDIS progress notes for transport should document the details such as the times of departure and arrival, the addresses or locations, the participant's state and behaviour during the journey, as well as any traffic incidents or delays.
4. Short-term Accommodation
NDIS Short-Term Accommodation (STA) is a type of service that offers participants a temporary respite environment that caters to their specific needs. Unlike other supports, such as NDIS group or personal services, STA is about the participant's experience of staying in a purpose-built setting, often overnight or for several days.
Therefore, NDIS progress notes for STA are not solely about the participant's progress; instead, they're about how the participant's behaviour adjusted to the new environment. Specifically, how the participant interacts with others (if they live in a group setting) and manage their daily routines in a different setting.
NDIS progress notes guidelines and requirements
The guideline for NDIS progress notes can vary based on the type of services, whether the services are group-based, personal, transport or short-term accommodation. Despite the discussed differences, below are some fundamental guidelines and elements to be included in NDIS progress notes for each type of service. Please keep in mind that each organisation will have different internal policies that might lead to additional rules for writing progress notes.
1. Group Services NDIS Progress Notes
Guidelines
- Individual Focus: While group services are delivered to multiple participants at a time, the primary focus of the NDIS progress note must be on each participant's behaviour, experience and progress.
- Goal-Oriented: The NDIS progress notes should document how group activities contribute toward the participant's NDIS goals.
- Respect Privacy: Service providers should avoid including sensitive or private information about other participants in the group when documenting individual progress.
What to Include
- Start with Basic Information: Service providers can start writing each progress note with the date, time, location, and duration of the group session. Besides, service providers should mention the nature of the session, the activities conducted, and the staff involved.
- Describe the Participant's Experience: Document the participant's level of engagement, participation, and interaction within the group. Additionally, service providers can capture their behaviour and mood.
- Highlight Progress: Document any progress, accomplishment or improvement that the participant makes in a group session, and how this progress contributes towards their NDIS goals.
- Incidents Report: It's also crucial to document any significant incidents (including alleged incidents) involving the participant during the group session.
2. Personal Services NDIS Progress Notes
Guidelines
- Detail-Oriented: The NDIS progress notes for personal services should be detailed and specific, capturing the individual's progress and response during the session.
- Regular Update: Regularly update the progress notes after each session to maintain an accurate record of the participant's progress and changes in their condition.
- Clear Objectives: Each note should show how the service given is helping the participant one step closer to achieving their NDIS goals.
What to Include
- Basic Details: Start the progress notes by documenting the date, time, location, service duration, the specific type of service provided, and the staff involved.
- Detail the Participant's Response: Clearly note what the participant did and said, how they felt, and how they reacted during the service.
- Connect to NDIS Goals: Clearly document how the service provided is helping the participant one step closer to achieving their NDIS goals. Besides, service providers can outline any progress or setbacks in their journey towards these goals based on the session.
- Incidents Report: It's also crucial to document any significant incidents (including alleged incidents) involving the participant during the group session.
3. Transport Services NDIS Progress Notes
Guidelines
- Journey-Focused: Unlike other services, the emphasis of NDIS progress notes for transport service is on the overall experience of the participant during their travels.
- Transparency: It's essential to maintain clear, transparent records for billing purposes, especially since transport services can involve various costs, such as tolls or fuel.
- Participant Experience: NIDS providers should note participants' expressed concerns or satisfaction, and how they accommodated specific needs during the journey.
What to Include
- Basic Journey Details: Each progress note should start with the date, time, pick-up location, drop-off location, duration of the journey, the staff involved and the vehicle used.
- Travel Conditions: Note any unexpected events or incidents during the journey, such as traffic delays, or weather issues, and how these events were managed to ensure the participant's comfort and safety.
- Participant's Interaction: Document the participant's mood, any conversation or feedback they gave, and general behaviour.
- Expenses Incurred: If applicable, progress notes should include any additional costs incurred during the journey, such as parking or tolls which are agreed upon with the participant or their plan manager.
4. Short-term Accommodation NDIS Progress Notes
Guidelines
- Participant-Centreed Care: Given the temporary nature of STA, it's vital to document how the participant adapts to the new environment, such as their daily activities, interactions, and any changes in their usual behaviour or routine.
- Continuity of Care: As STA serves as a temporary change from the participant's usual setting, it's crucial to document any new behaviours, preferences, or needs identified during the stay.
What to Include
- Basic Stay Details: Start with the date, duration, and location of the STA. Besides, service providers can note the reason for the stay, such as respite for caregivers, or trial of a new setting, and the staff involved in the participant's care.
- Daily Activities and Routine: Document the participant's daily activities, including personal care routines, meals, social interactions, and any changes in their typical routine.
- Participant's Behavior and Mood: Record the participant's mood, emotional state, and behaviour. Service providers also need to pay attention to any signs of anxiety, happiness, discomfort, or unusual behaviours and how staff respond to these.
- Incidents or Significant Events: Include any incidents or significant events that occurred during the stay, how they were managed, as well as their impact on the participant's future care or support needs.
- Feedback from Participant: If possible, document any feedback or comments provided by the participant regarding their stay.
- Transition Information: Provide any necessary information that will assist with the participant's transition back to their regular environment. This could include recommendations for changes to routines, new supports needed, or strategies that were particularly effective during the STA.
Common mistakes when writing NDIS progress notes
While the guidelines above are helpful for service providers to create effective notes, errors can sometimes occur and impact the quality of your NDIS progress notes. In this section, we'll look at some frequent mistakes when writing NDIS progress notes, and discuss how to correct them.
1. Group Services NDIS Progress Notes Mistakes
Generalizing Participant Experiences
Given the group activities, service providers may sometimes write notes that focus on the group's overall experience, instead of individual participants' experiences and progress.
- Example: The group enjoyed the music therapy session today. Everyone was engaged and appeared happy.
- Correction: During today's music therapy session, Adam enjoyed and engaged with other participants. He seemed particularly interested in the drumming activity and showed a noticeable improvement in his rhythm and coordination.
Lack of Goal Alignment
The note does not highlight how the group activities help the NDIS participant achieve their personal NDIS goals.
- Example: Adam took part in the group cooking activity.
- Correction: Adam actively participated in today's group cooking activity and successfully prepared a salad independently, which helps Adam one step closer to his NDIS goal of getting better at cooking independently.
Inadequate Detail
Key details such as the participant's level of engagement, interactions, and responses during the session may be inadequately recorded.
- Example: Adam attended the group reading session today. He read a story and talked about it with the group.
- Correction: Adam attended the group reading session. He chose a short story from the collection, read it aloud fluently with minimal assistance, and engaged in the group discussion about his favourite books with high concentration.
Revealing Others' Private Details
In trying to record a participant's interactions, service providers should not include private or sensitive information about other participants.
- Example: During the group game, Adam disagreed with Alex, who has a history of behavioural issues.
- Correction: During the group game, Adam disagreed with Alex. Our support staff intervened and the situation was peacefully resolved. After that, Adam returned to the game with a positive attitude.
2. Personal Services NDIS Progress Notes Mistakes
Inconsistency
A support worker alternates between writing progress notes immediately after the session and at the end of the day. As a result, the notes written later lack important observations and details.
Correction: Establish a consistent practice of writing progress notes immediately after each session. This ensures all key observations and details are captured.
Lack of Detail
Notes may lack sufficient detail about the participant's response to the service, changes in their condition, and their progress.
- Example: Adam had his regular speech therapy session.
- Correction: In today's speech therapy session, Adam practised their 's' and 'r' sounds using specific exercises. He showed a slight reduction in the frequency of the lisp compared to the previous session.
Failure to Link to NDIS Goals
If the note doesn't link the service provided to the participant's NDIS goals, it will be hard to track progress and the service's effectiveness.
- Example: Adam attended his scheduled occupational therapy session.
- Correction: During Adam's occupational therapy session, he worked on improving his hand-eye coordination with a series of exercises. We observed noticeable improvements that helped Adam one step closer to his goal of increasing independence in daily living tasks.
Missing Information
Important details such as the date, time, location, duration, and specific service provided can sometimes be overlooked.
- Example: Adam attended a 1-hour occupational therapy session.
- Correction: On June 30, 2023, Adam participated in a 1-hour occupational therapy session at ABC Therapy Centre from 2:00 PM to 3:00 PM, working on hand-eye coordination exercises to enhance his daily functioning skills.
3. Transport Services NDIS Progress Notes Mistakes
Overlooking Participant's Experience
NDIS providers may forget to include the participant's emotional state or feedback during the transport, focusing only on logistical details.
- Example: Jane was quiet during the ride to therapy today. We left at 10 AM and got there at 10:30 AM.
- Correction: On the ride to her therapy session, Jane was quiet. She spent the journey looking out the window. As I asked if she was okay, she nodded affirmatively. Jane gave a small smile as we arrived on time for her session at 10:30 AM.
Ignoring Travel Conditions
NDIS providers may forget to document the conditions or incidents during the travel that might have affected the participant's experience or safety.
- Example: We experienced some traffic on the way to the clinic, but we still arrived on time for the appointment.
- Correction: As we encountered a 10-minute traffic delay due to an accident on Station Drive, I informed Sam about the situation to keep him reassured. Fortunately, we arrived at the clinic safely and on time by taking Emu Road as an alternative route.
Missing Expense Details
NDIS providers may forget to include or explain additional expenses incurred during the transport.
- Example: Additional charges for today's session to cover travel expenses.
- Correction: Today's journey included passing through two toll stations, one costing $ 3.50 and the other $ 2.00, totalling an additional $ 5.50. These charges are in line with our agreed-upon terms for utilizing toll routes to ensure on-time arrival for Peter's therapy sessions. Receipts have been saved and are available upon request.
4. Short-term Accommodation NDIS Progress Notes Mistakes
Neglecting Emotional Observations
NDIS service providers may fail to document the participant's emotional state, mood changes, or behavioural observations during the stay.
- Example: Emma stayed with us for two nights. She stuck to her usual schedule, including her bedtime routine and morning walk.
- Correction: Emma stayed with us for two nights. She seemed anxious initially, especially during the first night, but gradually became more relaxed after staff spent extra time discussing her favourite books with her. By the second day, she was more comfortable, engaging more with other participants during activities.
Ignoring Participant's Feedback
NDIS service providers may fail to include any direct feedback, preferences, or requests expressed by the participant during their stay.
- Example: Tom was with us for the weekend respite. He had his meals on time and joined the group activities. No issues occurred.
- Correction: Tom stayed over the weekend for respite. He mentioned enjoying the outdoor garden area and asked if he could have his breakfast there. We accommodated his request, which he said made his experience more enjoyable.
Incomplete Transition Information
Not providing detailed information necessary for a smooth transition back to the participant's regular environment, or recommendations for future stays.
- Example: Sarah's three-day stay ends. She participated in all planned activities and followed the daily schedule. Ready for usual care to resume.
- Correction: We recommend maintaining a similar routine for her, as it seems to provide her with a sense of security. She also showed a newfound interest in gardening; continuing this at home could be beneficial.
NDIS Progress Notes Examples
1. NDIS Group Services Progress Notes Example
Date: June 30, 2023
Service: Group Art Therapy Session
Location: ABC Community Centre
Duration: 2 hours
Participant: John Doe
NDIS Goal: Within the next 12 weeks, improve John's social skills by initiating and maintaining conversations with at least one peer during each weekly group therapy session.
John participated in today's art therapy group session, and actively engaged in a group activity. He chose to paint a landscape and expressed satisfaction with his painting.
During the group-sharing part of the session, John confidently showcased his painting and passionately shared his love for nature. He also initiated a discussion with his new friend, Alex, and responded well to compliments and constructive feedback.
Overall, John expressed himself creatively through his painting and became more confident in discussing his favourite topic with his peers.
2. NDIS Personal Services Progress Note Example
Date: July 1, 2023
Service: Personal Physiotherapy Session
Location: XYZ Therapy Centre
Duration: 1 hour
Participant: Jane Smith
NDIS Goal: Over the next six months, improve Jane's mobility by increasing leg strength to the point of completing 10 consecutive squats without assistance.
Jane had her regular physiotherapy session today, focusing on leg-strengthening exercises. She completed 3 sets of 5 squats and lunges with minimal assistance.
Compared to the last session, Jane's stability and endurance were improved as she completed 1 more repetition of each exercise to reach 7 consecutive squats. Overall, Jane was satisfied with her progress and showed a positive attitude toward the challenging aspects of her therapy.
3. NDIS Transport Services Progress Notes Example
Date: June 30, 2023
Service: Transport to Vocational Training
Pick-Up Location: John Doe's Residence
Drop-Off Location: XYZ Vocational Training Centre
Duration: 45 minutes
Participant: John Doe
NDIS Goal: Within the next 6 months, John aims to attend vocational training three times a week to enhance his job skills and improve his confidence for future employment.
Today, John was scheduled for his vocational training session at the XYZ Vocational Training Centre. I arrived at his residence with our standard company van equipped with enhanced safety features to ensure a secure journey. John seemed ready and eager for the day.
The weather was a bit challenging, with unexpected rain causing some traffic delays. However, I reassured John and took an alternative route to avoid heavy traffic, ensuring we maintained our schedule. John appeared to be in a good mood, discussing his plans for the day and the skills he hoped to acquire from his session.
John was dropped off at the XYZ centre on time for his session and seemed confident as he walked in.
4. Short-term Accommodation Progress Note Example
Date: July 14, 2023
Service: Short-Term Accommodation Stay
Location: Sunshine Respite House
Duration: 3 days, 2 nights
Participant: Emma Smith
NDIS Goal: Emma is interested in exploring new environments.
Emma began her short-term stay on Friday evening. Upon arrival, she was a bit reserved but curious. Staff members introduced themselves and outlined the weekend's optional activities, emphasizing that she could participate as much or as little as she wished.
Over the weekend, Emma opted to try a variety of activities, showing particular enjoyment during the pottery class. She also spent time reading in the common areas and occasionally had short conversations with other participants.
Emma chose to spend her Sunday morning quietly, taking a walk in the gardens and later joining a group watching a movie.
As her stay ended, Emma shared that she enjoyed the experience of being somewhere new and was glad for the break in her routine.
NDIS Progress Notes Best Practices
In addition to the discussed guidelines, there are several best practices that NDIS service providers can adopt to enhance the quality of NDIS progress notes.
Maintain Clarity and Conciseness: Use precise language to convey your message. For instance, instead of writing, "James seemed a bit down in the afternoon." you might say, "James was fatigued in the afternoon."
Utilise Active Voice: Write in an active voice to make your statements more direct and easier to understand. Instead of "Miss Ella was escorted to her room" write "We escorted Miss Ella to her room."
Avoid Jargon: Avoid using industry-specific abbreviations or slang that might be unclear to others. For example, instead of writing, "Anna Brown was transferred to PC," write, "Anna Brown was transferred to Palliative Care."
Preserve Authenticity of Entries: If a mistake is made, simply strike it through, explain the correction, and then sign and date it. For instance, if you mistakenly record that a participant received medication at 8:30 p.m. when it was actually 7:30 p.m., you should correct it as follows: "Medication administered at 8:30 p.m. 7:30 p.m. Correction: 7:30 p.m. Signed: [Your Name], [Date]"
Stay in the Loop: Regularly review recent progress notes at the beginning of your shift. This practice keeps you informed about the participant’s current status and ongoing support requirements.
How to store and organise NDIS progress notes securely.
Ensuring your company's NDIS progress notes are securely stored and organised is a crucial part of delivering quality care. To avoid information loss, theft, or damage, here are 3 ways to store your NDIS progress notes securely:
NDIS Compliant Electronic Storage
Digital technology has revolutionised data storage. However, storing progress notes electronically comes with specific obligations under NDIS rules. Notably, all participant data and progress notes must be stored in a cloud-based system within Australia to maintain a high level of data security. Traditional methods like keeping records electronically on Word documents or Google Drive may not comply with these requirements.
As a result, using cloud-based systems designed for healthcare data storage like Comm.care, which uses an Australia-hosted AWS (Amazon Web Services) data centre, can ensure your data is securely stored and available to your team wherever and whenever you need it.
Restricting Access
Even though digital platforms offer convenient data access, controlling this access is crucial to prevent any unauthorized entry. Access to progress notes should be limited to specific staff members directly involved in the circle of care. In addition, service providers should regularly check and adjust these permissions to keep NDIS participant's data secure.
Regular Backups
Even with the most secure systems, it's crucial to regularly back up your data. This habit will prevent the risk of losing data in case of any unforeseen issues. Ensure your cloud provider offers automatic, regular backups and stores this backup data in Australia.
Streamline your NDIS Progress Note-taking Process.
A streamlined, user-friendly, and efficient care management software can significantly enhance the care delivery and progress note documentation of your organisation. Since 2013, our software, Comm.care, has revolutionised the way 800+ businesses manage and document their progress notes. Below are the key features that make Comm.care an invaluable tool for NDIS service providers:
Progress Notes & Timeline: Comm.care provides the capability to enter and access NDIS progress notes right at the point of care. This on-the-go accessibility enhances accuracy and timeliness in note-taking and information sharing. Besides, our "timeline" feature offers your team and participants a unified view of all participant data, documents, and care plans. By bringing your team, participants, and their families into one platform, Comm.care enables transparent and effective communication.
Roadmap: Our "roadmap" feature provides a comprehensive view of each participant's NDIS funding situation. This includes total available funding, budget allocation for each service, actual expenditure, budget utilisation rate, and remaining budget. This real-time financial information is crucial for service planning and management.
Everyone on the Same Page: Comm.care's "feed" feature facilitates easy and direct communication among colleagues, participants, and their families, ensuring everyone stays informed and engaged in the care process. Besides, Comm.care enables your team to share updates and comments on the participant's progress; as a result, it ensures that your participant can receive person-centred care.
Centralized Document Management: In line with NDIS requirements, Comm.care stores all participant documents and data in a secured cloud-based system located in Australia. As a result, Comm.care can help your business store all data securely and ensure your business's compliance with NDIS standards.
Book a demo now to explore how Comm.care can empower your team and streamline your business.
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Comm.care is a comprehensive platform designed to seamlessly streamline care management, invoicing, rostering, and compliance process. Comm.care offers a unified platform for organisations to collaborate with other care institutions and manage care for the elderly, people with disabilities, along with their families and friends.
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