How to Write NDIS Progress Notes — What to Include and What to Avoid

Why Progress Notes Matter

Progress notes serve three purposes at once:

• Operational: They inform the next shift of what happened, what the participant's current state is, and what needs follow-up.
• Compliance: They are evidence that the support was delivered, that the worker was present, and that care was provided in line with the support plan.
• Clinical: Over time they document patterns in health, wellbeing, behaviour, and progress toward goals — information that is essential for plan reviews, incident analysis, and clinical decision-making.

The Four Things Every Progress Note Should Cover

1. What care was provided

Specifically what supports were delivered during the shift. Not "personal care" but "assisted with shower, dressed in own clothing, prepared and assisted with breakfast." The more specific, the more useful the note is for both care continuity and compliance.

2. The participant's mood, wellbeing and presentation

How did the participant present during the shift? Calm, happy, distressed, fatigued, unwell? Were there any changes from baseline? This is clinical information that the next shift needs to be aware of.

3. Anything notable that occurred

Any falls, refusals, medical concerns, behaviour incidents, important conversations, community activities, or anything that deviated from the usual routine. If nothing notable occurred, a brief note to that effect is still useful.

4. Any follow-up required

Does something need to happen next shift? Does the manager need to be informed? Does a family member need to be contacted? Flagging these in the note ensures they don't fall through the cracks.

Objective Language — The Most Important Skill

The most common note-writing problem is the use of subjective, interpretive language instead of objective, observable description. The difference:

What Not to Include in a Progress Note

• Opinions about family members, other staff, or the organisation. Notes are clinical records, not personal diaries.
• Diagnoses or medical interpretations. Describe what you observe, not what you think it means clinically. Leave interpretations to qualified clinicians.
• Information about other participants. Notes belong to one participant. Never reference other residents by name in someone else's notes.
• Vague generalisations. "Had a good shift" is not a progress note. It tells the next shift nothing.
• Sensitive personal information that isn't relevant. Notes are discoverable — write as if a tribunal might read them.

The Handover Note — A Special Type of Progress Note

A handover note is written specifically to inform the incoming shift of the participant's current state and any priorities for the next shift. It should answer three questions: What happened? How is the participant right now? What does the next shift need to know or do?

Good handover reduces medication errors, ensures continuity of care, and means the incoming worker isn't starting blind. Many clinical incidents can be traced back to poor handover.

Training Staff to Write Better Notes

Most support workers are not trained clinicians. Note-writing is a skill that must be actively taught, not assumed. Effective training approaches:

• Show real examples — good notes and poor notes — and discuss the difference
• Use note templates with structured sections so workers are prompted to cover all areas
• Have a senior staff member or manager review notes in the first few weeks of employment
• Give specific feedback on individual notes rather than general guidance
• Set a minimum length — "at least 3 sentences covering what happened, how the participant presented, and any follow-up" — as a quality floor