Daily Care Notes / Visit Record

What goes in daily care notes?

Daily care notes are the record a home care worker writes at each visit: who came, when they arrived and left, what care they gave and how the person seemed. NICE calls the collection of these notes the care diary, a detailed day-to-day log of the care and support given that also shows the person's needs, preferences and experiences. You keep it in the person's home.

This template is written for home care visits. It gives one record for each visit, in eight short sections.

1. Visit details: date, planned time, actual arrival and leaving times, care workers, visit type and how you got in

2. How the person is today: how they say they feel, mood, pain, changes in health and any new marks

3. Care and support given, with a tick for each care plan task and room to say why one was not done

4. Food and drink, including what the person ate and drank and how much

5. Medicines, which points back to the MAR chart and the refusal record

6. Incidents, concerns, who you told and a message for the next worker or family

7. Leaving the home: person safe with a drink and call alarm in reach, doors secured, key returned

8. Sign-off by the care worker, a second worker on two-worker visits and a senior when audited

How to write good daily care notes

Write the record during the visit or before you leave, because records must be accurate, complete and made at the time. Stick to facts. Note what you saw, what you did and what the person said, in their own words where you can. Give enough detail to keep the family and the next worker fully informed.

If you have not seen the person for a while, read the recent entries before you start. Use black ink and no correction fluid: cross out a mistake with one line, then initial and date it. Never write key safe codes, door codes or passwords on the record.

The person can have a copy of their care diary if they want one.

Before you use it

Change the task list to match the person's care plan. If you use an electronic care record, copy these headings into it.

Medicines support goes on the Medication Administration Record (MAR Chart), not only in these notes. A new bruise or skin mark needs a Body Map Form, and a declined medicine needs the Medication Refusal Record, so keep all three with the care diary.