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What are the different types of session notes?
Support notes
Support notes are a record of the time you, the support worker, spent with your client. They describe the support you provided, key activities you both participated in and what was achieved during the session. They are helpful in case of an incident or dispute and useful for your client if they have, or are applying for, government funding and need to show how they are using support.
Health and Wellbeing notes
Health and Wellbeing notes only appear in your support hours form if your client has a Home Care Package. You will be prompted to select either No health and wellbeing changes observed or, if you did notice a change, to select one or more options from a checklist and add any relevant notes. These observations help your client’s Home Care Package provider monitor their health and wellbeing and meet their changing needs as soon as possible. Examples of topic areas that might necessitate a Health and Wellbeing note are: increased pain, weight change, mobility changes, appetite change, decreased motivation, refusal of usual support program, and positive improvements.
What to include in support notes
You should describe the support you provided, key activities that took place, and what was achieved during the session. The activities should match the type of service you were booked to provide during the session.
It is very important to write fresh notes for each session based on your observations and reflections from your time with your client.
Notes should be professional and objective.
Your client may ask you to take photos during the session to attach to their support notes. You must always ask for your client’s consent before sharing photos or videos of them on the platform.
Example support notes
Example One – Cleaning
I vacuumed and washed the floors and cleaned the kitchen and bathroom. We talked about my next visit and agreed that I’ll stay an extra hour next time to clean the oven.
Example Two – Social support and capacity-building activities
I met Chris at his home and helped him to use an app on his phone to look up train times. We walked to the station and caught a train into town and had ice cream and watched the ferries. Chris enjoys using the travel app and is becoming more confident in choosing the correct train platform and using his Opal card.
What to include in Health and Wellbeing notes
Your Health and Wellbeing notes should clearly and respectfully outline any changes you noticed regarding your client’s health or wellbeing.
Notes should be professional. You can include observations you’ve made about your client, but please try to stick to the facts.
Example Health and Wellbeing notes
Example One – Increased pain
I noticed that Joan seemed uncomfortable when walking and complained about pain in her hip.
Example Two – Mobility changes
I noticed that Mike had trouble standing up from his chair and didn’t walk around the garden like he usually does.
Who can read session notes?
Your support notes could be read by the following people, so it’s important to make sure they are professional and objective.
- The person managing your client’s Mable account and approving your support hours
- Your client’s support coordinator and/or HCP provider
- Mable finance or customer support team
- An insurance company claims assessor
- The Mable Trust and Safety Team
- In some circumstances, Mable may be legally obligated to disclose your support notes to a legal or regulatory body.
In the Support Hours section of your account, you have the option to turn sharing for Health and Wellbeing notes On or Off depending on whether you want your client or their coordinator to see the notes on their profile. Clients can request a copy of their Health and Wellbeing notes from Mable.
When sharing is turned off, Health and Wellbeing notes are shared only with a Home Care Package provider or client (upon request).
When sharing is turned on, notes can be viewed by your client in Support Hours if they are self-managed. For coordinator-managed clients, only the Home Care Package provider and coordinator can access your Health and Wellbeing notes. If your client is using NDIS funding, their coordinator or plan manager does not have access to the support notes or Health and Wellbeing notes.
How session notes can impact payments
Some provider organisations may ask you to accept their terms and conditions. These may include submitting accurate and timely support hours and notes.
If there is a significant gap between a support session and the time you submit your hours and notes, your support hours may be rejected, or your payment may be delayed. To prevent this from happening, submit your hours and notes in a timely manner.
You may also experience payment rejections or delays if your support notes are of poor quality or the activities don’t match the services you were booked to provide.
How to lodge an incident report
If any incidents occur during a session you’ll be asked to report this when you submit your support hours and notes. You must also report it to Mable.
There are some things to keep in mind when reporting on incidents.
Legislation requires some incidents to be reported to the NDIS Quality and Safeguards Commission or Aged Care Quality and Safety Commission within 24 hours, and processes and timeframes apply to other types of reportable incidents.
Please refer to the Mable Incidents and Complaints Management Policy for more information.
Cases of possible neglect or abuse
If you suspect neglect or abuse taking place, you must report it.
If your client is an older person you must make a report to the Aged Care Quality and Safety Commission as per the Serious Incident Reporting Scheme (SIRS).
Reportable incidents must be lodged using the SIRS Notice tile on the My Aged Care Service and Support portal.
If your client is a person with disability, you must make a report to the NDIS Quality and Safeguards Commission.
You must also report it to Mable as an incident and include your observations in your support notes.
If you have already submitted your support notes and they have been approved, you can submit an incident report on the Mable website.
If you are in any doubt, report the incident or contact us for assistance.
