Reporting That Helps: Observations, Not Interpretations

Create shift notes to instruct the following shift on what has occurred and what will follow.

Support workers notice changes that may not be mentioned when the appointment is scheduled: decreased appetite, more prompting, a new reluctance to use the stairs, a new routine that takes longer.

If notes are vague, judgmental or copied over, that valuable information goes down the drain. Documentation is factual and relevant, timely and related to the person's plan.

Why this matters for support workers

Quality is seen in a thousand little things in another person's home and community for the support worker. While having a plan is important, consent, respectful language, accurate observation and keeping to role is equally important. Consistency does not need to be rigidity if workers understand the purpose of a routine and the person can be involved in how the support is given to them.

What better coordination looks like

The easiest discipline is to differentiate between what you saw and what you think it means. Note the action taken, who was informed, and let the qualified professional(s) interpret the information.

Use concrete detail

Record what you observed, heard or were told, including the time, context and comparison to the person's typical manner.

Connect to the support

Note the prompt, assistance or response provided and how the person reacted.

Close the communication loop

Write the name of the person who received the concern, any instructions that were given within scope and what the next worker should know.

Make the change last

A helpful change is specific enough to be practised, but small enough to be reviewed. Decide who will do the first thing, where the decision will be written down and when the person will be asked if it helped or not. If multiple services are needed, check each service's readiness individually, not in a meeting. Keep what works, change what doesn't and eliminate short-term solutions that require the long-term effort.

Questions for the next review

What would “use concrete detail” look like from the person's point of view?

What is known and what has yet to be done?

What can the individual and the team see to determine if this strategy is working?

Keep the boundary clear

Avoid diagnosis, speculation on motives and personal opinions unrelated to the question. Avoid sending messages or using “informal” systems to communicate that could compromise privacy, unless an urgent pathway is needed for immediate contact.

A practical example

A worker recorded the participant pacing for 20 minutes and rejecting their normal activity, because the room was too noisy, instead of writing “agitated all afternoon”. The team could then make an environmental arrangement and see if the alteration makes a difference.