Participant Support Procedures > Participant Case Notes
Authorised by Chief Executive Officer
Revised Date: 23 April 2019
At the completion of each shift with participants, staff are asked to make notes in Carelink. These are done electronically, by mobile phone or computer.
Carelink has different options for allocating a program name to the notes. Most will use Shift Notes but there are also notes for the different supported employment areas.
The purpose of note-taking is:
•to indicate whether the shift went to plan or whether there were changes,
•to note whether there were any incidents or issues of concern
•to indicate whether the person’s goals are being achieved
•to provide evidence of support and/or issues that can be reviewed when the participant’s NDIS plan review approaches.
Notes should be professional – assume that the person’s family is reading them as you write, as they and the participant do have the right to see them
•Notes may be done on your mobile phone or, where this is not possible, texted or emailed through so that a Team Leader can copy them onto Carelink for you.
•Different areas have different note choices and these may be accessible on your phone depending on which participants you are supporting eg Green Fingers, Seawinds and Windward may be chosen for those sites rather than just Shift Notes.
•Ameeyk House notes can only be done at the house.
•Notes may be very brief but need to contain enough information that a reader can see what happened on the shift. Add some details where appropriate; if the individual is cooking, mention what was made. If having physical exercise, note what sort was done. If on an outing, mention where.
•If there were issues of concern record, without emotion, what they are. Document whether the person’s family or a Team Leader or Manager was informed. For serious issues that relate to health, wellbeing, behaviour and participant safety a Team Leader or Manager must always be consulted as it is important they be made aware of these. Notes can be emailed, or the worker may phone the Team Leader/Manager who can put the notes into a section called issues in Carelink, thus protecting the participant’s privacy
•For very private issues you consider reflect on the person’s dignity, please speak with a Team Leader as the notes may be written up in a different area of Carelink (such as CM Notes) that cannot be seen by all staff.