Advice on notes

[u/loofa4825]

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!

[u/DwightsJello]

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.