Writing Effective Shift Notes for Independent Support Workers: A Guide

As an independent support worker, writing shift notes is a critical part of delivering high-quality care and ensuring continuity for your clients. These notes serve as an official record of your work, documenting the support provided, any changes in the client’s condition, and details that can assist future workers, caregivers, or the client themselves. While shift notes might feel like an administrative chore, they are a powerful tool that can ensure consistent, person-centered care.

In this blog, we’ll break down what to include in your shift notes, tips for writing them effectively, and why they’re so important in your role as an independent support worker.

Why Are Shift Notes Important?

Shift notes are essential for several reasons:

• Communication: They provide valuable information to other support workers, family members, or healthcare professionals involved in the client’s care.
• Continuity of Care: Shift notes help ensure that there is continuity in the support provided, even when different people are involved in the client’s care on different days.
• Legal Documentation: They serve as formal documentation of the care you provided. In the NDIS environment, detailed records are essential for compliance and accountability.
• Reflection and Improvement: Reviewing your notes can help you reflect on your work, track progress, and adapt your approach to the client’s evolving needs.

What to Include in Your Shift Notes?

While every client is different, a few key elements should be included in every shift note. These provide a comprehensive picture of the support you’ve given and any relevant developments.

1. Date and Time
   Include the date and time of your shift. This is especially important when multiple support workers are involved, as it allows others to track who was with the client and when.
2. Client’s Wellbeing
   Start by describing the client’s physical, emotional, and mental wellbeing. Did they seem content, anxious, or unwell? Any changes in mood or energy levels? Use objective language, avoiding opinions or assumptions.Example:
   • Not Ideal: “John was really moody today.”
   • Ideal: “John appeared more withdrawn today, speaking less than usual and avoiding eye contact.”
3. Support Tasks Provided
   Detail the support you provided during the shift. This could include assistance with personal care (e.g., showering, dressing), meal preparation, medication reminders, and mobility assistance. Be specific.Example:
   • “Assisted Sarah with personal care including showering and dressing. Prepared a light lunch (salad and soup) and provided support with medication, confirming she took her morning dose of tablets.”
4. Activities and Engagement
   Include any activities the client participated in, whether it’s social interaction, going for a walk, or engaging in a hobby. Noting these details helps provide a holistic view of the client’s day and their quality of life.Example:
   • “Took James for a 30-minute walk around the neighborhood. He seemed to enjoy the walk, commenting on the weather and greeting neighbors.”
5. Concerns or Changes
   If you notice any changes in the client’s condition—whether physical, emotional, or behavioral—make sure to note them down. This might include anything from a new health issue, changes in mobility, or a shift in mood or demeanor.Example:
   • “Noticed some swelling in Mary’s right ankle. She mentioned feeling discomfort when walking and requested assistance with moving around more frequently than usual.”
6. Follow-Up Actions
   If there are actions that need to be followed up by the next support worker or family members, clearly state them. This ensures that everyone involved in the client’s care is aware of what’s needed next.Example:
   • “Recommend monitoring Sarah’s medication intake tomorrow morning as she mentioned feeling lightheaded after taking her evening dose.”

Tips for Writing Clear and Effective Shift Notes

1. Keep it Objective
   Stick to the facts, and avoid making subjective assumptions about the client’s behavior or condition. Describe what you see and hear, not what you think the client is feeling.
2. Be Specific and Concise
   Include specific details but avoid long, overly descriptive narratives. Shift notes should be concise yet informative.
3. Write in a Timely Manner
   Try to write your shift notes immediately after your shift, while the details are still fresh in your mind. This ensures accuracy and helps prevent important details from being forgotten.
4. Maintain Confidentiality
   Always ensure your shift notes are kept confidential and shared only with those who are directly involved in the client’s care, as per privacy laws and your NDIS obligations.
5. Use Consistent Language
   Developing a consistent style and structure for your notes can make them easier for others to follow. Consider using bullet points for clarity and always write in clear, plain language.

Example of a Well-Written Shift Note

---

Date: 7 October 2024
Time: 9:00 AM – 1:00 PM

• Wellbeing: John appeared slightly more anxious today, pacing the room and expressing concern about his upcoming medical appointment.
• Tasks Completed: Assisted with morning personal care routine (showering, dressing). Prepared breakfast (toast and scrambled eggs). Reminded John to take his medication, which he confirmed he took at 10:00 AM.
• Activities: Went for a 20-minute walk around the block. John engaged in conversation but seemed preoccupied.
• Concerns: John mentioned discomfort in his lower back during the walk. Suggested monitoring this during the next shift.
• Follow-Up: Ensure John’s discomfort is checked tomorrow morning and ask if he would like to inform his GP about the pain if it persists.

---

Conclusion

Writing effective shift notes is a core part of being a successful independent support worker. These notes not only provide essential information to other team members and healthcare professionals but also ensure your clients receive the best possible care. By following these guidelines and focusing on clarity, objectivity, and detail, you can create shift notes that are both informative and professional, contributing to better care outcomes for your clients.

By taking a little extra time to write quality shift notes, you are playing an integral role in supporting the safety, wellbeing, and quality of life for those you support.

How Blueset Makes Writing Shift Notes Easy

At Blueset, we understand that administrative tasks like writing shift notes can feel time-consuming, especially when you’re busy providing hands-on care. That’s why our platform is designed to make this process simple and efficient for independent support workers.

With Blueset’s streamlined interface, you can easily document your shift in just a few clicks. Our intuitive forms guide you through each section, and attaches each note to the shift, so you don’t need to worry about losing notes, or matching up times and days. With Blueset, you can easily keep track of all the necessary information, such as the client’s wellbeing, tasks completed, and any important observations in one place.

By using Blueset, you can spend less time on paperwork and more time focusing on what really matters—your clients. Our platform helps you stay organized, compliant, and efficient, making it easier than ever to run a smooth, safe, and successful independent NDIS business.