Examples of daily care notes

Daily care notes are one of the most important aspects of the delivery framework in health and social care. Supporting an individual’s support plan ensures the wellbeing of those receiving care services and reflects their progress towards their goals.

In this guide, we will look at different examples of daily care notes, what they are and why they are important, and how to write daily care notes in your care home.

What are daily care notes?

Daily care notes are a formal record that precisely represent events and the care delivered on each shift for individual service users. They have been designed to capture a more complete, personalised record of the needs, challenges and activities of the individual including health, demeanour and mood.

With these daily logs, carers can record changes, and review and update care plans as they see fit to keep track of a service user’s progress. As well as this, the information is available for all staff so communication is consistent across the team and accuracy is maintained for delivery of care and communicating with families.

Why are daily care notes important?

Information shared across health professionals

Daily care notes are important because they will be used by different members of staff for different reasons. They are the source of truth and must be accurate and as detailed as possible, so the information can support the level of care being provided. This promotes coherence and coordination between healthcare professionals, such as handing over notes for the next shift change, as well as visibility for families and loved ones.

Help make informed clinical decisions

Any changes in condition, medication and incidents, among other professional observations, are all logged in daily care notes which help team members make informed clinical decisions. This information reflects the progress a service user is making and can contribute to adjustments being made to care plans. In addition to this, they can also be used to ensure continuity of care with other healthcare services.

Maintain high quality of care

As daily care notes are updated every day, they keep a log of the standard of service being provided. Not only does this mean that healthcare professionals can ensure high-quality care is consistently being delivered, but families and loved ones can also be reassured.

Use as evidence in investigations

Following on from being used as evidence to support quality of care, daily care notes are part of a service user’s permanent legal record and they can be used as evidence in any legal proceedings, audits, and investigations. As a paper trail, if any information is falsified, inaccurate or missing and is thought to have contributed to mistreatment, the team member that recorded the note may be held accountable.

CQC compliance: good governance

Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 states that, “providers must securely maintain accurate, complete and detailed records in respect of each person using the service and records relating to the employment of staff and the overall management of the regulated activity.”

Daily care notes are a form of effective governance and systems to check on the quality and safety of care. They are evidence of the care being delivered, so if an inspection checks the notes, they will be able to see what you are doing on a daily basis.

What’s included in daily care notes?

In general, a daily care notes template will include:

• Time and date
• Event type
• Resident’s name
• Written note
• Name of person recording the event

Some other elements that may be included are:

• Changes in behaviour or emotional wellbeing
• Behaviour of concern including descriptions of what happened surrounding this
• Medication reactions
• Changes in physical appearance
• Dietary notes
• Any visits from healthcare professionals
• Any interventions or assistance given

It’s a good idea to include the resident in the writing of your daily care notes so they feel included in the process, can expand on the description of events, and are happy with what is written.

How to write daily care notes in a care home

Make sure that you always record the note as soon as possible, normally at the end of every shift, so the details are fresh in your mind. Writing the events in the order they happened is also recommended, with enough information so others can understand what happened.

No matter whether you handwrite or type the notes, you should always be concise and choose plain language; this is so the information can be easily scanned by the reader. However, there must still be enough information included so others can clearly comprehend the situation. Remember to state what occurred before, during and after an incident, and be specific regarding times, temperatures and other measurements.

Always remember to include both positive and negative occurrences; this includes any errors made by caregivers, such as your own. Plus, accurately describe the types of assistance given during each activity. Each individual’s goals in their care plans must always be at the forefront of your daily care notes, so every record is personalised to every service user.

Examples of daily care notes

There are many different formats you can follow for examples of daily care notes such as:

1.     SOAP

2.     STAR

3.     DAR

4.     GIRP

5.     SBAR

6.     CBE

7.     POMR

8.     Narrative

9.     Digital care management software

1.   SOAP method

One of the most common examples of daily care notes is the SOAP method because it promotes consistency and clarity which are vital. The anagram stands for Subjective, Objective, Assessment, and Plan. Subjective refers to how the service user is feeling, both regarding symptoms and feelings or concerns. Objective refers to more factual data, such as vital signs and test results. Assessment refers to both subjective and objective information being assessed to identify areas for improvement. Plan refers to the actions decided upon moving forward.

2.   STAR method

Another common example of daily care notes, the STAR method provides a comprehensive description which focuses on attention to vital details. The anagram stands for Situation, Task, Action, and Result. Situation refers to a specific event’s setting and context to help the reader understand. Task refers to the issue that arose and the Action refers to the actions taken to resolve it. Result refers to the outcomes from this event that can be used in a care plan moving forward.

3.   DAR method

This anagram stands for Data, Action, and Response. Data refers to an observation being made by the carer, action refers to any intervention that took place to try and resolve the observation, and response is the outcome of this at the time and in the future. This is a more streamlined method of documentation.

4.   GIRP

This anagram stands for Goal, Intervention, Response, and Plan. Although similar to the DAR method above, it differs due to its goal-oriented approach. By focusing on goals, interventions and evaluations can be easily guided.

5.   SBAR method

This anagram stands for Situation, Background, Assessment, and Recommendation. Also like the DAR method, situation refers to the occurrence noted by the caregiver, background is further information about the situation, assessment is the analysis made by the caregiver and recommendation is the action decided upon moving forward.

6.   CBE

CBE stands for Charting By Exception, also known as variation charting. This means only documenting deviations from an individual’s baseline using shorthand. It has been designed to reduce the amount of documentation.

7.   POMR

POMR stands for Problem-Oriented Medical Record which focuses on a service user’s  specific problem or issue. It is based on a data collection system that uses the SOAP method and this way, it is easier to track the progress outcomes.

8.   Narrative charting

Simply put, narrative charting has less structure than the methods above and uses a chronological way of documenting a service-user’s experience. This enables a more detailed and sequential record.

9.   Digital care management software

Nowadays, many care homes are utilising care management solutions like Log my Care to record daily care notes in a much more efficient way. With templates and guidance on best practice, it is even easier for caregivers to provide notes every day and access service user information whenever they require.

Saving carers time writing daily care notes, they can focus more on service user’s and delivering high-quality care. All notes are stored within the software, with the ability to share information between teams, family members and other health services. As an intuitive and easy-to-use platform, it speeds up the recording of care and delivers better continuity of care.

Book your 1-1 demo to see Log my Care’s electronic logs feature, alongside a host of other tools that simplify day-to-day processes, so you and your team can focus on delivering person-centred care.

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