Shift notes are an important way of documenting the support you provide. For insurance purposes, it is required that you detail what was done on the shift and make a special note should there be any incidents that occur. If there was an insurance claim made, the shift notes that you submit would be an important part of the evidence required to assess this.
Please keep in mind that the client has access to what you write on your timesheets for their reference as well so make sure your notes are professional and objective.
If you need to report anything in your timesheet such as possible neglect or abuse that you do not want to be displayed on your timesheet, please contact us at Mable so we can help you document this and report to the relevant authority in your state.
Here is an example of shift notes:
Today I arrived at Mr. Smith’s apartment at 5:30pm and assisted him to eat his dinner by cutting up his food and prompting him to use his cutlery. The client normally does not need assistance to cut up his food, but this week has been needing my assistance. After dinner, I cleaned up by washing the dishes, cleaning the surfaces and sweeping the kitchen floor. The client wanted to watch the news after dinner so we sat together and watched for about 30 minutes. At 7:30pm I assisted the client to bed by physically assisting him to use the toilet, brush his teeth and put on his pajamas. On the way to bed, the client became agitated and squeezed my arm. I spoke gently to him and slowly guided him to his bed. Once the client was settled in bed, I left him to sleep and then monitored a half an hour later to ensure he was still asleep in bed. I then left the apartment at 8:30pm.