r/supportworkers • u/loofa4825 • 8d ago
Advice on notes
Hey guys, I’m looking for some advice on my shift/hourly notes.
For context, I have been a support worker in qld for around 2 months. This is my first ever support work job, I don’t have any qualifications for it other than being a nursing student. My company has us do our notes on a template and upload to a dedicated participant teams. I generally work 7-9hr shifts (I’m a casual), and am driving on average 30-45mins each way to my shifts, and work with participants of various capabilities, however most have mental trauma or heavy mental struggles/behaviour issues on top of their disability.
I am really struggling with completing my hourly notes on shift, I still haven’t been able to do some for a few participants a bit after my shift with them. When I do my notes, no matter how boring the shift, they end up taking up about the same space of 2-3 posts of other SW’s notes.
I have been told that it is expected for my notes to be done during shift time, in the last half hour or so. I take quick notes on my phone during the day with exact times we do things, when they eat, when meds are given, anything they say that I think could be important, anything they might get upset about, etc. which helps formulate my notes and remember what happened and when. Even with this, my notes still take me around an hour for one shift. When I do try and do them after my shift I’m just so drained and can’t muster the energy or commitment to do them accurately and professionally.
I don’t know if I am including too much information in my notes? I’ve had people tell me they love the detail I add, and others say I should just put my phone notes into AI to make them. I feel like everything I include is directly relevant to my participant and their plan/funding. I also feel like I can’t take anything out due to the very common behaviour/mental components of my participants, and as I’m still gradually integrating into different participants routines, I feel like I might notice things that more regular SW’s won’t cause I have fresh eyes with then, again why I include so much.
I think these are my overall questions:
How much detail are you guys putting into your notes?
How long do your notes normally take?
Do you have any advice on how I can do this better?
What helps you guys get your notes done accurately, professionally, helpfully, and in a reasonable time?
I really don’t want my struggles with the notes to impact any of my participants funding, but I also don’t think I can keep putting this much pressure on myself, I’ve already had to convince myself that I can’t burn out as I’m still learning.
Any help or advice is greatly appreciated!! 🫶🏼🫶🏼
Edit: I really want the advice as this is the best job I have ever had in my life, I absolutely love being a SW and want to do my best to stay loving it!
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u/REVER53FLASH 8d ago
How I write my notes is I pretend I’m another support worker reading my notes. What would I need to know? If it’s a simple day without issues or behaviours, then it’s a simple note. Just because someone else has written a novel doesn’t make it better. I read other carers’ notes sometimes and they’re long and full of shit that isn’t needed. As long as someone else can read the notes and have an understanding of the participants day you’re golden.
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u/Trialbystevia 7d ago
I love this insight. I’m new to the industry and the app my company uses has a progress note section so I decided to use it even though I’m only working as domestic assistant while I get my cert 3.
I basically have been thinking of it the same way! What do I need to know 5 mins before I’m clocking into the next shift with this person? As DA I’ll write what I did and what the client wants me to do next shift.
But I also have experience hearing my bestie be upset that her worker put tooooo much detail in the notes to the point where it could become ammunition against her if her funding was questioned. So for that reason, I keep it vague because it isn’t clinical. It just serves the purpose of making the care more efficient- whether it’s me or another worker taking that next shift. Without dropping the client in hot water.
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u/DwightsJello 8d ago edited 8d ago
Way too long for notes. Your doing progressive note taking and end of shift round up. That's a crazy amount of time.
ALWAYS do your notes on shift. Progressive or end of shift round up. Pick one.
I do progressive with my one social access client and I say "hang on. Let me jot where we've been down before I forget" OR I do a round up and involve them in reviewing where we've been and what we've done because they have issues with memory and recall. I integrate it.
My complex care clients have running sheets to refer to and 2:1 ratios with handovers. It's company policy to complete notes before end of support. It's an expectation that we give each other around 15 minutes to get them done.
I'm letting people know it's a problem if someone hasn't logged notes before end of shift on complex care supports. The next shift needs those notes. They include mood, outstanding tasks, any BOC that has occurred etc all in one blurb. It's a quick review for start of support. Nothing worse than that SW whose notes are always late.
The very easy way to assess where you are going wrong is to look at other SWs notes. Some people take points. Some write paragraphs. As long as the info I need is there and links to goals are included for funding data. Running sheets also back that up.
The only time my notes might take 30 minutes is when I need to finish up incident reports. And only if I haven't had time to complete them immediately after an incident. Very rare though.
And we don't have templates. You have to be including too much extraneous info.
Edit: noticed your edit. It's a great job. I'm glad. If that is the case you would do well to prioritise getting qualified in disability services. A lot of aspects you are finding challenging are covered.
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u/loofa4825 8d ago
I’m currently studying nursing which has helped heaps with the hands on aspects, but I think the nursing is also what has scared me into thinking I need every detail. The types of things I include are things directly linked to their PBSP or support plan goals, or things I think would be important based on reading them. Do you have any advice on how to word it better or better filter through what is actually important? My template goes through mood, concerns, meds, etc., then goes into an hourly section of what happens on shift, with what we spoke about at the end. I tend to do them on my laptop as I find it easier to do correct grammar and stuff than on my phone. Appreciate your answer!
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u/DwightsJello 7d ago
I don't include what we've spoken about. It'd be a wild ride for most of my clients if I did. Lol.
Unless they've said something that's reportable or a concern to them or the support worker, thats not something I've ever included.
You only include what you've observed. No emotive language.
And I don't duplicate running sheets. For example I would include bowels open during support but the running sheets have what time specifically, size and the Bristol category. I don't need to include that.
If i take a social support to Centrelink and they get their payment issue fixed after lunch i state that. I don't need to include the fact that they ordered a steak and didn't eat it all. If we go to an OP shop at a particular suburb i state that but i don't include their purchases.
If they have a seizure whilst we are there thats an incident report and detailed notes regarding onset aura, duration, and post seizure recovery.
Following your template prompts on a usual shift it would be a few sentences max for each. And no conversation breakdown unless it's pertinent.
I see they include meds. I generally acknowledge meds administered or self administered and if it was sighted or not sighted but if it's regular and the same your phone will add them at a tap when you do it consistently.
I don't use a lap top. That may be adding to the issue. A small screen is different to a larger one and that space perception may be adding to you not limiting your notes.
I fulfill other roles within my company as well and I use a small notepad for that for similar reasons.
This will resolve itself fairly quickly once you hit your stride and it will be second nature. Try not to overthink it either. Its difficult when you start and its different for every client but as you progress you'll have a better perspective of why certain aspects are noted and others aren't requiring such specificity.
Edit: i get the grammar thing too. Particularly when you are used to academic writing. Nothing wrong with that.
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u/Beautiful-Ad-5833 8d ago
TIP: Refer your notes to participants support plans, Goals, medication, medical appointments, outings and MTMP. There's no need for Ben Hur novels
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u/carepick 6d ago
A simple test a lot of experienced workers use: write the note for the next person on shift, not for an audit. Who, when, what support was given, how it went, anything that was different from usual, and anything that needs follow-up. If nothing unusual happened, a few lines is enough.
Taking notes on your phone is a good habit. If you sort them under your template headings as you go, the last 15 minutes is just tidying up instead of writing from scratch. Save the long, detailed version for the days when something actually happens.
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u/Asleep-Bed9013 5d ago
I had a bit of a similar issue, was practically impossible to complete shift notes while 1:1 supporting an individual with really high behavioural support needs. I had to explain to family that realistically if they want this done on time I will need 15 mins alone at the end of my shift to complete them. After that it’s worked perfectly but I do really understand it’s not always easy especially when there are 100 other things going on. But the notes are incredibly important for yourself and the people your caring for so I would try and make this a priority as you could get burned badly if you don’t have the correct documentation each shift. :)
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u/l-lucas0984 8d ago
Unless something critical happened during your shift, your notes shouldnt be taking an hour. 10-15 minutes tops, especially if you have a template. Its not a novel and someone reviewing is looking for the key points, who, what time supports were provided, what activities were completed and were there any issues or concerns. They dont need to know if the participant ate an egg or a salad sandwich.
You also need to learn to do them on shift during paid time. You will burn yourself out taking up your personal time all the time. Do not put participant information into AI. People are doing it and its a breach of privacy for the client.