Writing NDIS Progress Notes

The NDIS Core Module, which you'll be audited against if you're on the Certification pathway, doesn't specifically require progress notes. However it does require, under support planning, for each support plan to be reviewed annually or earlier, that progress in meeting desired outcomes and goals is assessed, and that where progress is different from expected, you work with the participant to change and update the plan.

The best way to evidence this is with your progress notes.

Progress notes vs shift notes

Shift notes are an operational handover document recording what happened during a shift, including tasks completed, times, anything unusual, and what the next worker needs to know.

Progress notes record movement against the participant's goals and the strategies in their support plan. This is how you can assess whether a support plan is working.

A support coordinator, an allied health professional writing a therapy report, or a receiving provider at transition likely won't read your shift notes but may be interested in your progress notes.

Participant access to records

Participants are entitled to request access to the records you hold about them.

• Describe behaviour rather than diagnosing it, so "did not get out of the car for twenty minutes" rather than "was being difficult"
• Record what family members or other providers said, and who said it, rather than your opinion of them
• Write about the person the way you would speak about them if they were in the room

Progress note examples

Example 1

The goal in this participant's support plan is to increase independence with meal preparation.

Weak: Assisted David with dinner. He did well. Good shift.

Better: David prepared dinner with support. He chopped the vegetables himself and I did the stovetop. He needed prompting to check the recipe.

This is factual and specific enough that you could compare it to another note, but it doesn't connect clearly to the participant's goal or say anything about whether the strategy is working.

Strong: Goal: increased independence with meal preparation. David chopped all vegetables independently (first time without prompting, previously needed hand-over-hand). I managed the stovetop. He asked for the recipe to be read aloud twice rather than the four times noted last week. The visual recipe cards the OT suggested seem to be working. Next: try David managing the stovetop with me present.

The strong note names the goal, records change against a previous baseline, evaluates whether a strategy from the plan is working, and includes a plan for next time.

When progress is going backwards

Weak: Priya seemed flat again. Didn't want to go out.

Strong: Goal: attend community art group weekly. Priya declined to attend for the third consecutive week. She said she didn't want to see people. In the past month she has attended once out of four sessions, down from three out of four in April. I asked what would make it easier and she said the group has gotten bigger. Flagging for support plan review.

The indicator is explicit that where progress differs from expected outcomes and goals, you work with the participant to change the plan, so it's important to record when things aren't working.

What to include in a progress notes

• The date, and the worker's name
• Which goal or support plan strategy it relates to
• What was observed, factually
• How that compares to before, where you can
• Whether a strategy in the plan is working
• Anything to follow up, and who's doing it

Common oversights

Activity recorded instead of progress. Notes that describe what was done rather than what changed, which belong more in shift notes than progress notes.

Judgements presented as observations. Words like "agitated", "non-compliant", "attention-seeking" and "manipulative" aren't useful.

Nothing links to the support plan. You're measuring progress against the goals in the support plan, so it should be referenced.

Only good news. Ensure you're recording when things aren't working, as well as when they are.

Copy and paste. Identical or near-identical wording repeated across weeks.

Notes written days or weeks later. Detail degrades quickly, so build the expectation into both your procedure and your rostering.

How progress notes are used

Support plan reviews. The annual review, and any earlier review triggered by a change in the participant's needs or circumstances.

Reviews of risk management strategies. Periodic reviews should be completed to see whether risk strategies are working, with changes when required.

Therapy reports at plan review. An allied health professional writing a report to the NDIA draws on what your workers recorded. VALID's 10 Steps to Excellent NDIS Therapy Reports is a useful read for seeing what those reports need to demonstrate, and therefore what your notes have to support: evidence of need, quantifiable progress against goals, and the risk of not providing a support. It's from 2018, so the Administrative Appeals Tribunal it refers to is now the Administrative Review Tribunal.

Transitions. Where a participant moves to another provider, the receiving provider may want to know about progress against goals. The Core Module requires transition risks to be identified, documented and responded to.

Incident investigations and complaints. Notes written at the time are your record of what happened and when.

A participant's funding can rely on whether there's evidence that a support is working, or that they still need it.

What to put in place

Set out in your procedure what each document is for and when each one is completed. Give workers a progress note structure that puts the goal in the note rather than leaving them a blank box. Cover both documents in induction, including what each participant's goals are. Read a sample of notes yourself every month. Bring the notes to the support plan review.

Paperbark's Certification Toolkit helps you build your support planning and records policies, including progress note requirements, from your answers about how you actually work.