Shift progress notes are crucial documents in the disability support sector, serving as detailed records of care provided to clients. Following the guidelines set forth by the National Disability Insurance Scheme (NDIS) Code of Conduct ensures that these notes are accurate, informative, and compliant with legal standards. Here’s a comprehensive guide on how to effectively write a shift progress note in accordance with NDIS requirements.

Understanding the Purpose of Shift Progress Notes

Shift progress notes document the care and support activities undertaken during a shift with a client. They serve multiple purposes:

• Legal Compliance: Ensuring adherence to NDIS standards and regulations.
• Communication: Facilitating communication among support workers, clients, and other stakeholders.
• Monitoring and Evaluation: Tracking the client’s progress and any changes in their condition.
• Continuity of Care: Providing a clear record for future caregivers to understand the client’s needs and preferences.

Components of a Shift Progress Note

A well-written shift progress note typically includes the following components:

• Client Information: Name, NDIS participant number, and any relevant medical or support history.
• Date and Time: The exact timeframe of the shift.
• Objective Observations: Objective descriptions of the client’s behavior, mood, and physical condition.
• Activities Undertaken: Detailed account of tasks completed during the shift, such as personal care, medication administration, or household chores.
• Client Responses: Any notable responses or reactions from the client during the shift.
• Incidents or Concerns: Record of any incidents, changes in health status, or concerns raised during the shift.
• Future Recommendations: Suggestions for future care based on observations made during the shift.

Writing Style and Language

• Clarity: Use clear and concise language, avoiding jargon or abbreviations that may not be universally understood.
• Accuracy: Ensure information is accurate and factual, avoiding assumptions or personal opinions.
• Objectivity: Maintain objectivity by focusing on observable behaviors and facts rather than interpretations.
• Confidentiality: Respect client privacy and confidentiality at all times.

Tips for Effective Shift Progress Notes

• Timeliness: Complete notes promptly after the shift while details are fresh in your mind.
• Detail-Oriented: Include specific details that are relevant to the client’s care plan and NDIS goals.
• Consistency: Follow a consistent format and structure for all shift progress notes.
• Legal and Ethical Considerations: Adhere to NDIS Code of Conduct guidelines regarding confidentiality, respect, and duty of care.

Reference and Compliance

• To ensure compliance with NDIS standards, refer to the official NDIS Code of Conduct and related resources
• NDIS Code of Conduct: Available on the official NDIS website (ndis.gov.au).
• Training and Guidelines: Access training materials and guidelines provided by NDIS for support workers.

Conclusion

Writing shift progress notes according to NDIS Code of Conduct guidelines is essential for maintaining high-quality care and legal compliance in the disability support sector. By following the outlined steps and referencing official NDIS resources, support workers can create detailed, accurate, and respectful shift progress notes that contribute to the well-being and continuity of care for NDIS participants.

For more detailed information, please visit the official NDIS website or consult with your organization’s policies and procedures regarding shift progress note documentation.

Sample Shift Progress Note

Verify Client Information:

• Client Name: Sarah Thompson
• NDIS Number: 4XXX 9XXXX 4XXX
• Date of Birth: 25/09/1990

Date & Time of Shift:

• Date: 19 May 2025
• Time: 9:00 AM – 3:00 PM
• Support Worker: John Matthews

Shift progress note:

9:00 AM – 9:30 AM:
Support worker arrived at client’s residence. Client was awake, alert, and appropriately dressed. Engaged in a brief discussion about the day’s plan, which included attending a GP appointment, shopping, and participating in a local art class. The client appeared slightly anxious about the GP visit.

9:30 AM – 10:30 AM – GP Appointment:
Transported the client to Smithfield Medical Centre for a scheduled GP appointment. The client was seen by Dr. Evans regarding her recent medication side effects (mild dizziness). The GP adjusted the dosage and updated her prescription. The client communicated well during the session and was reassured by the doctor’s advice.

10:30 AM – 11:00 AM – Medication Administration:
Returned home and assisted the client in administering her morning medication (under supervision as per care plan). The client took 1x 10mg Sertraline tablet as prescribed. No adverse reactions observed post-administration.

11:00 AM – 12:00 PM – Shopping Assistance:
Supported the client to the local supermarket. A shopping list was pre-prepared. Items purchased included groceries and personal hygiene products. The client was engaged and made choices independently with minor prompts for budgeting. No mobility issues observed.

12:00 PM – 1:00 PM – Household Chores:
Supported client in completing light household tasks, including vacuuming, folding laundry, and kitchen cleaning. The client was motivated and actively participated. Provided encouragement throughout, enhancing the client’s confidence in her independent living skills.

1:00 PM – 1:30 PM – De-escalation Support:
Client became mildly agitated following a phone call from a family member. Employed de-escalation techniques including calm verbal reassurance, redirection, and offering space. The client responded well and returned to a calm state within 10 minutes. No physical aggression or risks noted.

1:30 PM – 3:00 PM – Community Participation:
Accompanied client to the local community center to attend an art therapy class. Client actively participated, interacted with peers, and completed a painting project. The session appeared to have a positive impact on her mood and social engagement.

(Support Worker Signature)