ScenarioPlusby Waiver Academy
‹ Write It Right

Pocket guide · Documentation

Write It Right

If it isn't written down, it didn't happen.

  1. Show the support"Good day" tells the next shift nothing. A good note says what the person did, the support you gave, and how they did, linked to their goals. That's what the team, the nurse and the person's plan can actually use. Episode 1: Good Day
  2. If it isn't written, it didn't happenNews passed on at handover is easily lost. When you add something late, write it as a late entry with today's date and time, and say where the information came from. Never backdate a note. Episode 2: If It Isn't Written Down
  3. Their words, not labelsLabels like non-compliant hide the real reason. Write the person's own words and what you saw. Their words often point to the real problem, like shoes that hurt, and lead to a real solution. Episode 3: Her Words, Not Mine
  4. Correct, never eraseNever delete or rewrite an old entry. Add a correction with today's date, your name, what was wrong, and what really happened. If the mistake affected someone's care, tell the nurse and complete an incident report. Episode 4: Never Change Yesterday
  5. Every day gets its own wordsCopied notes look like nobody was there, and they hide the changes that matter. Write each note fresh, about what really happened that day. Something is always different. Episode 5: Copy, Paste, Problem
  6. Small notes add upOne note about a skipped lunch may not stand out. Three notes from different staff show a pattern. When everyone writes what they see, every time, the team catches problems early. Episode 6: The Note That Saved Her
  7. Label late entriesIf you forget to document something, add it as soon as you can as a clearly labeled late entry, with today's date and time, then describe what happened and when. Never back-date a note to make it look like it was written earlier. Follow your agency's late-entry policy. Episode 7: Late Entry
  8. Hand off in writingA spoken handoff is helpful, but it isn't enough. Write important changes in the shift log before you leave: what happened, when, what you did and how the person is now. The next staff, and the ones after them, can only act on what they can read. Episode 8: Say It, Then Write It
  9. Keep records privateThe people we support have a right to privacy. Don't photograph, text or post their records, names or health details on personal phones or group chats. Share information only through your agency's secure system, and only with people who need it for their care. Episode 9: Not in the Group Chat
  10. Sign only what you didYour signature says you did or saw something yourself. Never sign for a count, a task or a note you didn't do or check, even when someone in charge asks you to hurry. Do the check, then sign. It protects the people you support, and you. Episode 10: Read Before You Sign