Daily Care Notes: A Comprehensive Guide with Examples

Daily care notes are very important in health and social care. They help keep a detailed record of the care given to people. This record helps caregivers know what has been done and what needs to be done next.

These notes allow caregivers to communicate care needs to each other and help understand how a care receiver is doing. Whether in a care home, hospital, or at home, maintaining good care notes are important for keeping track of progress, noticing changes in health, and following the care standards.

Taking daily care notes is important in many settings, such as care homes, hospitals, and when providing care for people at home.

In this article, we’ll look at why daily care notes are important, how to write them well, and give examples.

When health and social care staff write and maintain good daily care notes, caregivers can improve the care they provide and ensure that everyone is open and honest within their organisations.

🟣Related: How to write a good hand-over note – Top 10 tips.

Key Takeaways

1. Why Daily Care Notes are Important: They help keep track of a person’s care, show changes in health, and allow caregivers to communicate well with each other.
2. Tips for Writing Good Notes: Be accurate, use simple words, stick to the facts, and follow a clear structure. Always include key details like date, time, actions, and results.
3. Mistakes to Avoid: Don’t use hard words, forget important details, or wait too long to write notes. Make sure the notes are clear, polite, and correct.
4. Good vs. Bad Notes: Good notes are clear, detailed, and focus on the person’s needs. Bad notes are vague, unclear, and not helpful for care.
5. Use Templates for Consistency: Using simple templates helps make sure the notes are easy to write and follow, keeping care organised and clear.
6. Training Courses: Effective Communication Training and Record Keeping Training for Healthcare Staff.

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What Are Daily Care Notes?

Daily care notes are written records that show the care given to a person during a shift or a certain time.

These notes include important details like:

• Activities done with the person
• Medicines given
• Changes in health or mood
• Any incidents or things noticed

Care notes are used in places like care homes, hospitals, and when caring for people at home.

The main reason for writing daily care notes is to make sure care continues smoothly- especially between shifts without staff making guessing. They help caregivers know what the person (care receiver) needs and how they are doing.

Care notes also:

• Show that safe and good care is being given
• Are useful for checks, inspections, and following the rules
• Help spot patterns or problems so the care plan can be changed if needed

Good daily care notes make sure the person gets the best care possible.

Who is the Daily Care Note for?

Daily care notes are for anyone who receives care services. They are especially important for:

• Older Adults: In care homes or at home, care notes help ensure consistent care.
• People with Disabilities: Care notes are crucial for tracking progress and communicating among caregivers.
• Individuals in Hospitals or Care Homes: Care notes ensure continuity of care and compliance with regulations.
• Those Receiving Home-Based Care: Care notes help caregivers coordinate and provide personalised care.

These notes are used by caregivers, healthcare staff, and sometimes family members to ensure that care is organised and of high quality. They help in understanding a person’s needs, tracking their progress, and ensuring they receive the right care at all times.

This way, everyone knows what to do, and the person gets good care.

What details should be included in daily care notes?

A 24-hour daily care notes should include these important things:

1. Time and date of the note
2. Name of the person being cared for
3. Name of the person writing the note
4. What the person did and how they acted
   • What they ate
   • How they moved around
   • Who they talked to
   • How they felt
5. Information about medicines
   • What medicine was given
   • How much and when
   • Any problems from the medicine
6. Changes in health
   • New signs of sickness
   • Changes in breathing, heart rate, or temperature
   • Any hurts or falls
7. Care given
   • What help was given
   • How the person reacted to the help
8. Talks with doctors or nurses
9. How the person feels emotionally
10. What activities they did
11. Any problems or worries
12. What they ate and drank

The Care notes should be easy to read and information should be accurate. They should talk about what the person needs and use respectful words.

It’s important to write the notes as soon as possible after events happen to keep them correct and so you don’t miss key information.

Importance of Taking Daily Care Notes

Daily care notes are very important. They help in many ways:

1. Keeping Care Consistent: Care notes help everyone know what care a person needs. This is useful when different people care for someone.
2. Tracking Health: Care notes show how a person’s health is changing. This helps find problems early.
3. Helping Caregivers Talk: Care notes make it easy for caregivers to share information. This helps them work together better.
4. Making Care Better: Writing down what happens each day helps caregivers see what works well and what needs to change.
5. Following Rules: Care notes show that caregivers are doing their job correctly and following the rules.
6. Keeping People Safe: Good care notes can prevent mistakes and keep people safe.
7. Showing What Happened: If someone asks about the care given, care notes can show what was done and why.

Care notes are used in many places like care homes, hospitals, and when caring for people at home. They help make sure people get the best care possible.

How to Write Effective Daily Care Notes

Writing good daily care notes is important for accuracy and clear communication.

Here are some simple tips:

• Be Accurate: Write things down as soon as they happen to keep them correct.
• Use Simple Language: Don’t use hard/difficult words or shortcuts or abbreviations – use Please instead of Pls.
• Be Clear and Short: Share only the important details, no extra information.
• Stick to the Facts: Write only what happened, not what you think or feel.
• Follow a Format: Use the same layout for all notes to keep them the same.

Include These Important Things:

• Time and date
• What happened (like giving medicine)
• The person’s name
• What you saw (like how the person felt or acted)
• What you did
• What happened after.

Sign Off Properly: Put your name and sign at the end of the note so people know who wrote it.

Examples of Good Daily Care Notes

Example 1: Medication Administration

Date/Time: 4th March 2025, 8:00 AM

Note: Administered 500mg paracetamol as prescribed for headache relief. Resident drank water with ease and reported feeling better within 30 minutes. No adverse reactions observed.

Recorded By: Sarah T.

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Example 2: Personal Care

Date/Time: 4th March 2025, 9:30 AM

Note: Assisted Mr. John Doe with morning hygiene routine (shower and grooming). Noted slight redness on left elbow; applied prescribed cream as per care plan instructions. Mr. Doe expressed satisfaction with assistance provided.

Recorded By: Emily R.

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Example 3: Behavioural Observation

Date/Time: 4th March 2025, 2:00 PM

Note: Resident appeared withdrawn during lunch but ate half the meal (chicken soup). Encouraged social interaction by inviting them to join group activities; resident agreed but remained quiet throughout the session. Will monitor closely for further changes in mood.

Recorded By: James L.

Best Practices for Writing Daily Care Notes:

• Be accurate and on time: Write down what happens right away or soon after to make sure your notes are correct.
• Use simple and clear language: Avoid hard words or short forms that might confuse people.
• Be honest and stick to the facts: Write only what you see or know, not your own thoughts or opinions.

Include key details:

• Date and time of the event
• Resident’s name
• What happened (e.g., medication given)
• What was done
• The results or what happened after
• The name of the person who wrote the note

• Think about the person: Be kind when you write about them.
• Write important stuff: Write about big things that happen with health or behavior.
• Use full sentences: This makes your notes easy to read.
• Be clear: Explain things well so others understand.
• Write about good and bad things: Tell about anything unusual that happened.
• Be professional: Keep your notes polite, even if you know the person well.
• Use the same form: This helps keep your notes tidy.
• Think about the care plan: Make sure your notes match what’s in the person’s care plan.

If you follow these tips, you can write good care notes. This helps everyone work together to give the best care.

10 Common Mistakes We Have Seen in Daily Care Notes

Mistakes to Avoid When Writing Care Notes:

1. Using Hard Words: Don’t use words that others might not understand. Use simple words.
2. Leaving Out Important Things: Always write down important details like the date, time, person’s name, and your name.
3. Being Too Vague: Don’t write things like “The person seemed fine.” Instead, say “The person ate most of their meal and felt okay.”
4. Waiting Too Long: Write your notes soon after things happen so they are correct.
5. Writing Your Feelings: Only write what you see or do, not what you think or feel.
6. Spelling Mistakes: Check your spelling and make sure numbers are right. Read over your notes.
7. Writing the Same Thing: Don’t keep writing the same things every day. Make each note different.
8. Not Writing About Problems: Always write down if something goes wrong or if there’s a problem.
9. Messy Notes: Keep your notes tidy and easy to read.
10. Not Being Polite: Always write your notes in a polite and professional way, even if you know the person well.

If you avoid these mistakes, you can write good care notes that help take good care of people.

Examples of Good and Bad Daily Care Notes

Good Daily Care Note	Bad Daily Care Notes
Date/Time: March 5, 2025, 8:00 AM Resident: Mr. John Tone (JT) Note: Assisted JT with his morning routine, including a shower and dressing. Noted slight redness on his left elbow; applied prescribed cream as per care plan. Mr. Doe appeared comfortable and expressed gratitude for the assistance. Recorded By: Emily R.	Date/Time: March 5, 2025, 8:00 AM Resident: Mr. John Tone Note: “Helped John shower and get dressed. His arm looked red, so I put some cream on it.”
Date/Time: March 5, 2025, 12:30 PM Resident: Mrs. Sarah Smith Note: Smith ate lunch (chicken soup and bread) but left half of her meal uneaten. She appeared quieter than usual and declined to join the group activity afterward. Will monitor her mood and appetite closely. Recorded By: James L.	Date/Time: March 5, 2025, 12:30 PM Resident: Mrs. Sarah Smith Note: “Sarah didn’t eat much at lunch and didn’t want to do anything after.”
Date/Time: March 5, 2025, 3:00 PM Resident: Mr. Michael Brown Note: Administered prescribed medication (paracetamol 500mg) for mild headache as per care plan. Mr. Brown reported relief within 30 minutes and resumed reading his book comfortably. No adverse reactions observed. Recorded By: Sarah T	Date/Time: March 5, 2025, 3:00 PM Resident: Mr. Michael Brown Note: “Gave Michael his meds for a headache. He seemed fine after.”
Date/Time: March 5, 2025, 9:00 PM Resident: Miss Lucy Taylor Note: Miss Taylor reported difficulty falling asleep last night due to noise outside her room. Provided earplugs and discussed other strategies to improve sleep quality. Will follow up tomorrow to assess effectiveness. Recorded By: Mark P., Night Shift Supervisor	Date/Time: March 5, 2025, 9:00 PM Resident: Miss Lucy Taylor Note: “Lucy couldn’t sleep because it was noisy. Gave her earplugs.”

Key Differences

Good Care Notes:

• Are detailed and specific
• Are professional
• Focus on what was done, what was seen, and what happened after
• Think about the person’s needs

Bad Care Notes:

• Are not clear
• Don’t have enough information
• Use words that are not polite or professional
• Don’t follow a good order

Good care notes help everyone understand what happened and make sure care continues smoothly. Bad notes can cause confusion or gaps in care.

Templates for Daily Care Notes

Using simple templates can make writing notes easier and help keep records consistent. A basic template might include:

Section	Example Entry
Date/Time	4th March 2025, 10:00 AM
Resident Name	Jane Smith
Activity/Event	Morning exercise
Observations	Participated actively; no complaints
Actions Taken	Encouraged hydration post-exercise
Outcome	Resident reported feeling energised
Recorded By	Mark P., Care Assistant

Final Note:

In the end, daily care notes are very important for giving good care and keeping people safe. Writing clear and correct notes helps see how things are changing, track progress, and follow the rules. By using good methods and forms, caregivers can make sure their notes are complete and easy to read.

Whether you work in a care home or help people at home, writing good care notes is crucial for giving care that focuses on the person and building trust with families, inspectors, and other caregivers.

Good care notes help improve the lives of those you care for. They also help build trust and make sure everyone is responsible for their actions. By following good practices, caregivers can make sure care continues smoothly, reduce mistakes, and support the well-being of the people they care for.

Are You Ready to Improve Your Care Notes?

Do you want to write better daily care notes? Writing clearly and keeping good records are very important for:

• Continuity: Making sure care continues smoothly.
• Safety: Keeping people safe.
• High-Quality Care: Giving the best care possible.

Book your team for our expert-led effective communication and record keeping training. You also call choose the e-learning option on Communication and Record Keeping Online Training.