3 Tips for More Person-Centred Progress Notes

A person-centred approach to home care places the client at the centre. Getting to know your client as a person and recognising their individuality is key, as is seeing the client as an expert in their own health and care. It is an approach to care that emphasises 'doing with, not doing for' and builds on a client's strengths and capabilities. 

Encouraging a more person-centred approach is likely to improve the quality of care and support people to be more active in their care. This can lead to:

• Greater satisfaction with care ¹
• Better health outcomes² 
• Improved staff morale³

For home care providers, encouraging a more person-centred approach involves practical changes to the way care is planned, delivered, reported and communicated including the way progress notes are written. 

Here are our top tips for making your progress notes more person-centred.

1. Include Progress against the client's care goals

Person-centred progress notes are focused on the client and written from their perspective.

This means avoiding assumptions and recording what the client does or says during the visit that is directly relevant to their care. Observing changes in behaviour, emotional state, physical wellbeing, or physical appearance are also important and should be recorded.

Key things to observe:

• What did they say?
• What did they do?
• What did we discuss together?

Example:

2. Write from the client's perspective

A person-centred approach to care goes beyond simply addressing needs; it considers the individual and their goals. Progress notes can be made more person-centred by recording progress against previously communicated goals and recording any preferences and goals the person communicates during the visit. 

What to include:

• Actions taken to support the achievement of goals as outlined in the care plan or previous progress notes
• Recording new goals or preferences communicated by the client
• Recording supports that may be needed to help the client achieve goals

Examples:

3. Write client-friendly notes

A person-centred approach to care places value on supporting clients to access and understand information relevant to their own care. Making progress notes accessible and easy to read can support clients and their families to participate in and have greater control over their own care. Avoiding language that may cause unnecessary confusion or distress is also important.

Top tips for progress notes that clients can read:

• Write clearly and concisely 
• Record notes in a logical and sequential manner
• Avoid jargon, abbreviations and acronyms
• Be empathetic and avoid language that may cause offence
• Remain objective, avoid personal opinions

Blog by Karen Larsen-Truong

Need help writing person-centred Progress Notes?

We know that Progress Notes are a vital part to communicate how your team is delivering quality care to your clients. That's why DSC Software has features such as Client Checklist, Automatic Progress Notes and more that streamline your Progress Notes process to get more done in less time. 

If you want to know more, check out how you can make Progress Notes simpler in this blog by cliking the link below!

Sources:

1. De Silva D. Helping people share decision making, The Health Foundation, June 2012, p.12. www.health.org.uk/publications/evidence-helping-people-help-themselves
2. Hibbard J, Gilburt H. Supporting people to manage their health: An introduction to patient activation. The King's Fund, 2014
3. The King's Fund. Leadership and engagement for improvement in the NHS: Together we can. London: The King's Fund, 2012

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