What should care staff write in visit notes?

• What was done. Personal care, meals, medication given or prompted, tasks from the care plan. Tick what was done and say what was not, and why.
• How the person was. Mood, appetite, mobility, pain, skin, anything you noticed. Compare with their normal, not with an abstract idea of well.
• What was different. A new bruise, a missed meal, confusion that was not there last week, a fall, a visitor, a request. Different is the thing an inspector, a nurse or a family member will look for.
• What happens next. Who you told, what you asked for, what the next visit should watch. A note that ends with a handover is a note that does its job.

Write what you saw and heard, not what you concluded. "Declined breakfast, said she was not hungry, ate half a banana at 10:15" is evidence. "Being difficult about food again" is an opinion that will read badly in six months. If you need to record a concern, record the observation that caused it and then say you are concerned.

Avoid abbreviations only your team understands, and never write anything about a person you would not be comfortable reading to them. They, or their family, have a right to see it.

Medication is where notes most often fall short. Record what was given, when, and from which pack. If the person refused, record the refusal, what you said, and who you told. If a dose was missed or given late, that is a near miss and it goes in the note and in the incident system, not just in your head. A medication record that shows a refusal handled properly is a sign of a good service, not a bad one.

Some things need a phone call as well as a line in the note: a fall, a safeguarding concern, a sudden change in condition, a person who is not there when you arrive. Make the call, then write down that you made it, to whom and when. The note is the record that you did the right thing; it is not the right thing itself.

The single biggest improvement most providers can make is timing. A note written before the carer leaves the house is accurate, short and useful. A note written from memory on Friday is vague and long. Electronic care records make the first one normal: the carer opens the visit on their phone, ticks the tasks, writes two lines and moves on. In Exhale Care Solution that note is tied to a visit that was verified by location, so the record shows not just what was written but that the writer was there. Stopping missed visits covers the other half of that.