Shift Notes User Guide

STEP 1

Open your shift

From your roster, select the allocated shift. Review:

• Participant name

• Date and shift time

• Support location

• Any shift-related forms

• Mileage requirements

When arriving for support, select Clock In.

STEP 2

Navigate To Progress Notes

Select the Progress tab located at the bottom of the screen. If no notes exist, you will see the "No Notes" screen.

Select the + button in the bottom right corner.

STEP 3

Create A Progress Note

Select Progress Notes.

Only use:

• Progress notes to record what occurred during the shift and the support provided.

STEP 4

Complete The Progress Note

Complete every section before saving. For a detailed guide on what to include in your progress notes, please refer to the section "A Step-by-Step Guide to Completing Each Section of the Progress Notes" below, after Step 6.

STEP 5

Review And Save

Before selecting SAVE:

• Check spelling and grammar

• Ensure notes are factual and objective

• Confirm all sections have been completed

• Confirm incidents have been separately reported if required

Select SAVE in the top right corner.

STEP 6

Recording Mileage

If transport occurred during the shift, return to the shift details screen where you first clocked in, scroll down and select Mileage.

Enter the total kilometres travelled by the support worker during the support shift. This amount must be entered in both the Carer Mileage and Transport Mileage fields, as shown in the example below. Please leave all other fields blank.

Provide a brief description

Good Example - Transported participant from home to local shopping centre in Kincumber and return. OR Suburb to suburb – Drive around Wollongong to Warrawong shopping centre and return home.

Avoid - Drove around. Travel. N/A.

Select SAVE.

SHIFT TIME

Record the rostered shift duration. Good example - 6 hours | Avoid - All day

OBJECTIVE

Good Example - Community access support focusing on social engagement, confidence building and independence skills.

OR

Support provided to develop meal preparation skills and increase independence within the home environment.

Avoid - Went out today. Community access. Had fun.

2:1 SUPPORT

Indicate whether the participant was supported by two staff members.

Good Example - Yes, Support delivered alongside second support worker as rostered. OR 1:1

Avoid - Worked with another worker.

OBSERVATION AND INTERACTION

Describe:

• Activities completed

• Supports provided

• Participant engagement

• Community participation

• Skill development

• Level of prompting required

Good Example

Participant attended the local shopping centre and café. Support was provided with budgeting, ordering lunch and making purchases. Participant engaged positively throughout the outing and independently interacted with community members with minimal prompting.

OR

Participant participated in basketball activities at the recreation centre and demonstrated good engagement throughout the session. Verbal prompting was occasionally required to maintain focus on the activity.

Avoid

• Went shopping.

• Had a good day.

• We went out and got lunch.

• Participant was great.

BEHAVIOUR, SAFETY AND WELLBEING

Record:

• Mood and emotional presentation

• Behaviours of concern

• Risks identified

• Safety concerns

• Significant events

Good Example

Participant presented as calm and regulated throughout the shift. No behaviours of concern were observed and no safety risks were identified.

OR

Participant became frustrated when a preferred activity was unavailable. Staff provided reassurance and offered alternative options. Participant accepted redirection and continued with the planned activity.

OR

Uneven surfaces were identified during a community walk. Staff maintained close supervision and adjusted the route to minimise risk.

Avoid

• Participant was difficult.

• Participant was rude.

• Participant was angry all day.

• Everything was fine.

HEALTH AND PERSONAL CARE

Record:

• Food and fluid intake

• Personal care provided

• Toileting assistance

• Manual handling

• Health concerns

Good Example

Participant consumed a sandwich, fruit and water during the shift. Verbal prompting was provided to encourage hydration. No health concerns observed.

OR

Participant was supported with showering in accordance with their support plan. No concerns identified.

OR

No personal care support required during this shift.

Avoid

• Ate lunch.

• Had food.

• Shower completed.

MEDICATION

Record:

• Medication administered

• Who administered it

• Whether prompting was provided

Good Example

No medication administered during the shift.

OR

Participant self-administered prescribed medication following verbal prompting from staff.

OR

Medication administered by participant's parent whilst on support.

Avoid

• Took medication.

• Medication done.

• Had tablets.

GOALS REVIEW

Describe progress made towards participant goals. Examples may include:

• Independence

• Emotional regulation

• Physical activity

• Socialisation

• Community participation

• Transport training

• Employment skills

Good Example

Participant independently ordered lunch and completed payment using EFTPOS with minimal prompting, demonstrating progress towards independence and community access goals.

OR

Participant successfully utilised coping strategies following disappointment and returned to the planned activity after a short break, demonstrating progress towards emotional regulation goals.

OR

Participant engaged positively with peers during a group activity, supporting socialisation and community participation goals.

Avoid

• Worked on goals.

• Goals achieved.

• Participant did well.

INCIDENT REPORT

If an incident occurred:

1. Select YES

2. Complete an Incident Report in ShiftCare

3. Notify management

Examples include:

• Injury

• Medication error

• Aggressive behaviour

• Missing participant

• Vehicle accident

• Property damage

• Restrictive practice

• Safeguarding concerns

Good Example

YES – Incident report submitted and management notified.

OR

NO – No incidents occurred during the shift.

Avoid

• Something happened but not serious.

• Didn't bother reporting.

BREAK TAKEN

(Required for shifts exceeding 5 hours)

Good Example: Yes – 30 minutes | OR No break taken

Avoid

• Had lunch

• Break

• Don't remember

Objective vs Subjective Language

Avoid (Subjective): Participant was lazy and didn't want to participate.

Better (Objective): Participant declined participation in the planned activity despite encouragement from staff.

Avoid (Subjective): Participant was rude.

Better (Objective: Participant raised their voice and stated they did not wish to continue the activity.

Avoid (Subjective): Participant was angry.

Better (Objective): Participant appeared frustrated, raised their voice and walked away from the activity before returning after staff reassurance.

Important Reminders

Shift Notes Are Not Incident Reports

If an incident occurs:

• Complete your progress note.

• Complete an Incident Report.

• Notify management.

FINAL CHECKLIST

Before submitting your note ask yourself:

• Have I explained what support I provided?

• Have I described the participant's engagement and response?

• Have I recorded any health, wellbeing or safety concerns?

• Have I linked activities to participant goals?

• Is my note factual and professional?

• Have I completed an Incident Report if required?