Writing NDIS Progress Notes Accurately: A Comprehensive Guide

Now you know that shift notes are essential in documenting patient care. But what exactly should you include in a progress note? Well, that's the question! Here are some tips to help you write practical NDIS care notes:

1. Use the SOAP format:

The SOAP format is a widely used method for writing NDIS progress notes. SOAP stands for Subjective, Objective, Assessment, and Plan. Here are a few NDIS progress notes examples to help you better understand the format:

 Subjective:

The patient reports her mood has been "up and down" since her last session. She has been having difficulty sleeping and feeling more irritable than usual. She reports that her appetite has been poor and she has trouble concentrating at work.



Objective:

The patient appears to be in some distress. She has dark circles under her eyes and seems to have lost weight since her last visit. She reports that her energy levels are low and she has difficulty completing work tasks.

 Assessment:

The patient is experiencing symptoms of depression. She is at risk of developing complications if her symptoms are not adequately treated.

 Plan:The patient will be started on a course of antidepressant medication. She will be referred to a therapist for weekly sessions. She will be asked to keep a mood journal to track her progress.

2. Be specific:

When writing progress notes, it's essential to be as specific as possible. This will help ensure that the NDIS Care notes are accurate and can be easily understood by other team members.

3. Use medical terminology:

When writing progress notes, it's important to use medical terminology. This will help ensure that the notes are accurate and can be easily understood by other care team members.

4. Keep it concise:

NDIS Care notes should be concise and easy to read and understand. Try to stick to the facts, and avoid including unnecessary information.