NDIS Progress Notes: Common Mistakes to Avoid

ndis progress notes: a man writes in his notebook alongside an open laptop in a modern office environment

NDIS progress notes help ensure patient care is accurately tracked and communicated appropriately. However, there are common mistakes that can hinder their effectiveness. This blog will identify these typical errors, explain their potential impact, and actionable steps for improvement.

We will categorise progress note mistakes by four main types of service: NDIS Group Services, NDIS Personal Services, NDIS Transport Services, and Short-Term Accommodation. While the mistakes are categorised by service type, they are also relevant across various other service types.

Generalising Participant Experiences

When documenting NDIS progress notes, it’s important not to summarise the group’s experience but to detail a participant’s unique experience and progress. For instance, a note like “The group enjoyed the music therapy session” generalises the experience without individual insights.

A more effective approach is to focus on each participant’s engagement and progress: “Adam enjoyed the session, showing particular interest in drumming, which improved his rhythm and coordination.” This method ensures that each individual’s unique journey is captured and acknowledged.

Lack of Goal Alignment

Progress notes should not only state the activities participants engage in but also how these activities contribute to achieving their individual NDIS goals. For instance, simply noting that “Adam took part in the group cooking activity” lacks depth.

A more insightful approach would be, “Adam actively engaged in the cooking activity, independently preparing a salad, and improving his independent cooking skills.” This approach highlights personal progress toward specific goals within group settings.

Inadequate Detail

When documenting NDIS Personal Services, it’s crucial to capture a participant’s engagement and response. For example, a note like “Adam attended the group reading session” is too broad.

A detailed approach should be: “Adam chose and read a story aloud, showing improved fluency and actively participating in a discussion about his favourite books, demonstrating his focused engagement and communication skills.” This detail offers a clearer picture of Adam’s participation and progress.

Revealing Others’ Private Details

When documenting a participant’s interactions in group settings, it’s crucial to respect the privacy of other participants. For example, noting that “Adam disagreed with Alex, who has a history of behavioural issues” inappropriately discloses another participant’s personal information.

A more appropriate note would focus solely on the event and the resolution, such as “Adam disagreed with another participant, which was quickly resolved by our staff, allowing Adam to re-engage positively with the activity.” This approach maintains confidentiality while accurately documenting the incident.

Inconsistency

Consistency in recording progress notes is crucial. When support workers alternate their documenting routine; for example, documenting sessions immediately or waiting until the end of the day, the quality and accuracy of the notes can suffer. Notes taken sometime after the session may miss critical observations and details of the session.

To ensure accurate documentation, it’s recommended to establish a consistent routine where progress notes are written immediately after each service session. This routine will capture all critical details of the sessions. It also means its less likely to be forgotten.

Lack of Detail

Progress notes sometimes fail to capture detailed responses of participants to the services provided, their condition changes, and their progress. For instance, a note stating “Adam had his regular speech therapy session” is too vague.

A more detailed note would specify the activities Adam engaged in, such as “In today’s session, Adam practised ‘s’ and ‘r’ sounds, showing a noticeable improvement in reducing his lisp frequency.” This approach provides a clear detail about Adam’s progress and response to the therapy session.

Failure to Link to NDIS Goals

Progress notes should detail how the service contributes to the participant’s NDIS goals to track progress and the service’s impact effectively.

For example, rather than noting “Adam attended his occupational therapy session,” a more informative note would detail the activities and their relevance to Adam’s goals, such as “Adam worked on hand-eye coordination exercises during his session, showing progress toward his goal of increasing independence in daily tasks.” This detailed approach ensures a clear connection between service delivery and goal progression.

Missing Information

Including comprehensive details such as date, time, location, duration, and specifics of the service in progress notes is crucial. For instance, instead of stating “Adam attended a 1-hour occupational therapy session,” a more detailed note should be: “On June 30, 2023, Adam participated in a 1-hour occupational therapy session at ABC Therapy Centre from 2:00 PM to 3:00 PM, focusing on hand-eye coordination exercises to improve his daily functioning skills.” This level of detail enhances the clarity and usefulness of the progress notes.

Overlooking Participant’s Experience

When documenting NDIS Transport Services, it’s essential to note more than just the logistics.

For example, instead of simply noting the times of travel, like “Jane was quiet during the ride,” a more insightful note would include observations about the participant’s emotional state or feedback, such as “Jane was contemplative, often gazing out the window, yet she acknowledged when asked about her well-being, giving a small smile upon arrival.” This approach provides a fuller picture of the participant’s experience during the transport.

Ignoring Travel Conditions

It’s crucial to record any conditions or incidents during the transport journey that could impact the participant’s experience or safety. For instance, instead of only noting the traffic jam, a detailed note should describe any incident that causes the traffic jam (if any), and how the problem is handled to ensure the on-time arrival.

For example, as we encountered a 10-minute traffic delay due to an accident on Station Drive, I informed Sam about the situation to reassure him. Fortunately, we arrived at the clinic safely and on time by taking Emu Road as an alternative route.

Missing Expense Details

When documenting NDIS transport services, detailing any additional expenses incurred during the journey is crucial. For example, today’s journey included passing through two toll stations, one costing $ 3.50 and the other $ 2.00, totalling an additional $ 5.50. These charges are in line with our agreed-upon terms for utilising toll routes to ensure on-time arrival for Peter’s therapy sessions. Receipts have been saved and are available upon request.

Neglecting Emotional Observations

When documenting STA services, NDIS providers must capture more than just the participant’s schedule. They should note any emotional changes or behaviours observed during the stay to provide a comprehensive view of the participant’s experience.

For instance, Emma stayed with us for two nights. She seemed anxious initially, especially during the first night, but gradually became more relaxed after staff spent extra time discussing her favourite books with her. By the second day, she was more comfortable, engaging more with other participants during activities.

Ignoring Participant’s Feedback

Capturing the participant’s direct feedback, preferences, or requests is essential.

For example, Tom stayed over the weekend for respite. He mentioned enjoying the outdoor garden area and asked if he could have his breakfast there. We accommodated his request, which he said made his experience more enjoyable.

Incomplete Transition Information

Ensuring detailed information is provided for a smooth transition back to the regular environment is crucial.

For instance, an effective note would provide insights for future care, such as “Sarah adapted well to the new routine, which seemed to offer her a sense of security. She also developed an interest in gardening, an activity that could be beneficial to continue at home.” This approach gives a clearer picture of Sarah’s experience and actionable recommendations for her ongoing care.

Provider Institute Best Practice Tip

We’ve explored common mistakes in documenting progress notes across various NDIS service categories. From overlooking individual feedback to missing out on crucial details about the care experience, these errors can significantly impact service quality.

By recognising and rectifying these common oversights, service providers can enhance their progress notes, and improve the care and support delivered to NDIS participants. Case notes are also particularly important if there is an incident or complaint – so that you can refer back to the detailed notes to see any trends or insights to help with investigations. If you are interested in learning more about progress notes best practices, we recommend you to check out Pnyx’s NDIS Progress Notes Ultimate Guide.

NDIS Group Services Progress Notes Mistakes