Writing a good progress note: what to include

How a support worker writes a note in the support worker app at the end of a shift, what a useful note contains, and the checks the note must pass before it can be submitted.

Before you begin

• You are on the shift in the support worker app and signed in.
• The participant has goals in their care plan (needed to tag goals).

Open the note from your shift

1. In the app, open the shift you are working (from Today or Roster).
2. Tap Write note in the quick actions. The Progress note screen opens, linked to the shift; the shift’s place and times show under the title.
3. If the shift has more than one participant, tap the participant the note is about under Participant. With one participant on the shift, they are chosen for you.
4. You can also open a note from the participant’s profile (People, then the person) with Write a progress note, or from the Before you clock out list with Write.

Fill in the note

1. Under Goals this note supports, tap each goal you worked on. Tagged goals count as evidence for care plan reviews; a shift note with no goal is flagged Missing goal.
2. Under the mood question (How was … today?, with their first name), choose a mood: Great, Good, Okay, Low or Upset. A mood is required.
3. Use the prompt chips (What we did, Goal progress, How they felt, Choice and control, For the next shift) to add a heading line, then write under it.
4. Write at least 10 words. The word count under the text box turns green once you reach it.
5. Add photos under Photos if they help (they are stored on the record, not on your phone).
6. Under Flags, switch on Possible incident or Health concern if either applies.

Submit the note

1. Tap Submit note at the bottom. The button tells you what is still missing, for example Choose a mood or Write at least 10 words.
2. If you switched on Possible incident, the incident report opens next so you can report it straight away.
3. If you switched on Health concern, the confirmation says the RN on call is notified.
4. The note goes to your team leader for review. Once approved it is locked to the record.

With no signal, the note is saved on the phone and sent when you reconnect.

What a good note includes

Write facts you saw and heard, not opinions. Keep it plain and respectful: the person may read it.

1. What you did together, in order, with times for anything important.
2. How much support the participant needed and what they did themselves.
3. Choices the participant made and anything they asked for, in their words where you can.
4. How they seemed (mood, health, sleep, eating) and anything unusual.
5. Progress towards the goals you tagged, with a concrete example.
6. Anything the next shift needs to know.

Tips

• Notes are checked on submit: notes under 25 words are flagged Short for the reviewer, and a note submitted more than 24 hours after the shift is flagged Late entry. These are the default settings; your organisation can change them.
• You can only write one main note per person per shift. If you need to add something after submitting, tell your reviewer.
• The Draft with Axis AI and Check my note options work only when your organisation has the Axis AI add-on. See Drafting notes with Axis AI (coming soon).

If something goes wrong

The app says “A note for this shift already exists”.

You already submitted a note for this participant on this shift. Open it from the participant’s Notes tab instead of writing a second one, and ask your team leader to return it if it needs changing.

The server says “Not your shift: Only workers on this shift can write its note.”

You are not rostered on that shift. Check you opened the right shift. Team leaders can write a late entry for a shift they were not on; it is flagged Late entry.

Submitting fails with “Write at least N words (you have M)” or “Tag at least one goal worked on.”

Your organisation has set a higher minimum length, or made goal tags compulsory. Add detail or tag a goal and submit again.

No goals show on the note screen.

Goals load when you are online. If you are online and still see No goals recorded, ask the coordinator to add goals to the care plan.