Progress notes (sometimes called care notes or shift notes) are one of the most important parts of providing safe, high-quality NDIS supports. They not only help track the day-to-day experiences of participants, but also demonstrate compliance, support continuity of care, and provide valuable insights into progress toward NDIS goals.
Have you found yourself asking: What exactly should I include? How do I write notes that are clear, professional, and useful?
This guide outlines best practice requirements for writing NDIS progress notes and includes examples to help you write notes that are consistent, compliant, and person-centred.
Why NDIS Progress Notes Matter
NDIS Progress notes are more than just paperwork. They:
- Provide a clear record of the supports delivered.
- Ensure continuity of care between staff.
- Show evidence of progress toward participant goals.
- Protect both participants and providers in the event of incidents, complaints, or audits.
- Support compliance with NDIS Practice Standards.
Best Practice Principles
When writing progress notes, keep these principles in mind:
- Objective and factual – Record what you observed and did, not opinions or assumptions.
- Accurate and complete – Capture all relevant details from the shift or session.
- Timely – Write notes as soon as possible after providing support.
- Clear and professional – Use simple, respectful language without jargon or slang.
- Person-centred – Reflect the participant’s choices, voice, and dignity.
- Confidential – Only include information relevant to the participant’s care and supports.
What to Include in NDIS Progress Notes (with Examples)
A high-quality note doesn’t need to be long—it just needs to cover the right areas.
1. Participant Information
- What to record: Name, date, time, location.
- Example: “John Smith – 1 Sept 2025, 2:00–6:00pm, at home and local park.”
2. Supports Provided
- What to record: Activities completed, assistance given, equipment used.
- Example: “Assisted John with meal preparation (pasta and salad). Supported John with mobility when using his walking frame. Took John to the park for community access.”
3. Participant’s Condition / Presentation
- What to record: Health, mood, behaviour, communication.
- Example: “John appeared cheerful and engaged during cooking. He reported mild knee pain when walking, rated 3/10.”
4. Progress Toward Goals
- What to record: Link back to NDIS goals.
- Example: “John independently chopped vegetables with minimal prompting, demonstrating progress toward his goal of building cooking skills.”
5. Risks, Incidents, or Concerns
- What to record: Safety issues, incidents (fact-based).
- Example: “At 3:45pm, John tripped on uneven ground in the park. No injury observed. Supported John to sit and rest. Supervisor notified.”
6. Health and Medication
- What to record: Medication administered/refused, side effects, health interventions.
- Example: “John took prescribed medication (Panadol 500mg at 5:00pm) as per schedule. No side effects observed.”
7. Participant Voice
- What to record: Participant’s own words.
- Example: “John said, ‘I feel proud I made dinner mostly on my own today.’”
8. Communication with Others
- What to record: Family, guardians, professionals.
- Example: “John’s sister visited briefly at 4:00pm. Discussed upcoming GP appointment scheduled for 5 Sept.”
9. Staff Actions and Follow-Up
- What to record: Actions taken, handover items.
- Example: “Encouraged John to use knee brace for additional support. Handover to night staff to continue monitoring knee pain.”
Useful Formats for NDIS Notes
Two common structures can help support workers write consistent notes:
SOAP Method
- S – Subjective: What the participant says.
- “John said, ‘I’m feeling tired today.’”
- O – Objective: What you observe.
- Example: “John rested on the couch for one hour during shift.”
- A – Assessment: Your interpretation.
- Example: “Reduced participation in activities likely due to fatigue.”
- P – Plan: What’s next.
- Example: “Encourage rest, handover to next staff to monitor.”
DARE Method
- D – Description: “Supported Sarah with showering and dressing.”
- A – Action: “Provided verbal prompts and set up equipment.”
- R – Response: “Sarah responded positively, smiling and chatting throughout.”
- E – Evaluation: “Sarah completed most tasks independently. Will continue encouraging independence.”
Do’s and Don’ts
Do
✔ Write factually: “Participant refused medication at 8:00am.”
✔ Use professional, neutral language.
✔ Record promptly after the shift.
✔ Link your notes to goals or support plans.
Don’t
✘ Write opinions: “Participant was being lazy.”
✘ Leave gaps that others can’t follow.
✘ Use future tense: “Will take medication tomorrow.”
✘ Include irrelevant personal details.
Final Thoughts
Well-written NDIS progress notes make life easier for everyone: participants, support workers, and organisations. They ensure participants receive safe, consistent, person-centred supports, while also keeping providers compliant and audit-ready.
By following best practice principles—focusing on objectivity, respect, and completeness—you’ll not only meet your responsibilities as a support worker, but also contribute meaningfully to the participant’s NDIS journey.
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