Care Notes Phase 5 — Run Your Practice

About daily care notes

1Complete one note per shift. Fill it out at the end of the shift while details are fresh.

2Write what you observed — not what you interpreted. "Client refused breakfast" not "client was being difficult."

3Print and keep a copy. Over time these notes protect you if questions ever arise about care quality.

Phone

Daily Care Note

Client

Date

Shift Start

Shift End

Services Provided This Shift

Bathing Dressing Grooming Meal preparation Feeding assistance Medication reminder Mobility assistance Transfers Incontinence care Light housekeeping Companionship Transportation

Other:

Client Status

Overall condition

Good Fair Poor Declined from last visit

Mood

Pleasant Neutral Anxious Agitated Confused

Appetite

Good Fair Poor Refused meal

Fluid intake

Adequate Minimal Refused

Pain reported

None Mild (1–3) Moderate (4–6) Severe (7–10)

Mobility

Baseline Slower than usual Required more help Near fall / fall

Observations & Notes

Write what you saw and heard — objective, factual. If you didn't observe it directly, say so.

Communication

Did you contact family or care team today?

Called/texted family Left voicemail No communication needed

Summary of any communication

Caregiver Signature

Time completed

About incident reports

1Complete one any time something unusual happens — fall, injury, behavioral episode, refusal of care, medication concern, property damage.

2Write immediately after the incident — same day, before you leave the shift.

3Always notify the family. Keep a copy. If there's any chance of legal involvement, keep the original.

Phone

Incident Report

Client

Date of Incident

Time of Incident

Location

Incident Type

Select all that apply

Fall (no injury) Fall with injury Injury (not fall-related) Behavioral episode Refusal of care Medication concern Medical episode (chest pain, seizure, etc.) Environmental hazard Property concern

Other:

Severity

Minor — no injury, no emergency response Moderate — injury or significant distress Serious — 911 called or medical care required

Description of Incident

Write exactly what happened, in sequence, in your own words. Include what you saw, what you heard, and what the client said or did. Do not speculate about cause.

Client Condition

Condition before incident (if known)

Condition after incident

Immediate Actions Taken

List each step you took in the order you took them.

Notifications

Family notified?

Physician / agency notified?

911 called?

Notification details (who, when, response)

Follow-Up Required

Caregiver Signature

Report completed at