How to write a great checkout note!

App
How to write a great checkout note!

A very important part of the help and care you provide is leaving a note in the app at the end of your visit that contains information on how the visit went, the Members wellbeing or any other observations.

How do I leave a checkout note in the app?

Every time you finish a visit, the secure notes you leave about any changes or observations about a member are analysed by our remote care monitoring system Lookout™. It identifies members who may need more or proactive care. This is presented to trained Five Good Friends health professionals who make assessments. This information leads to benefits for the member through extra help or important changes to a help plan, so please leave notes and accurate visit ratings when you checkout. It means we are able to pick up changes and identify potential problems earlier than traditional providers. You can learn more about Lookout™ here and how to leave a checkout note in the app here.

What should I write about in a checkout note?

Checkout notes can include any changes you observed in the Member, their life, health or home. This might include changes in their physical or emotional well-being, behaviours of concern, participation in activities, feedback from medical appointments, dietary notes or medication support provided.

It’s understandable that notes might only get left when there is a change or significant event that occurs during a visit. Who wants to read “Lovely day, all good, had a cuppa and chatted” over and over? Well actually…we do. Understanding what is “normal” for a Member can be just as important in understanding their current health as getting notified when there is a sudden change.

  • Think about the W's - Where did it happen? When did it happen? What happened and how did you respond? Why did it happen? How did it happen?

Here are some examples of changes, observations or general health and wellbeing considerations you may comment on in your checkout notes:

  • Emotional well-being, mood, cognition and mental health e.g John said he has been feeling anxious this week and has made an appointment with his psychologist. I noticed his face looked pale and his hands were clammy.
  • Changes in behaviour or behaviours of concern e.g Mary has been asleep in bed when I've arrived for my visits at 11am for the past 2 weeks. She is usually up and ready for the day when I arrive and has often already been out for a walk. Mary said she's been feeling tired and wants to stay in bed.
  • Mobility e.g I observed John was unsteady on his feet today and held onto my arm while we did the shopping.
  • Personal care and appearance e.g I noticed Mary was wearing the same clothes as yesterday and said she had not showered for a few days.
  • Skin integrity e.g John has a cut approximately 2 cm on this left hand, it appears red and bruised. John said he knocked his hand in the garden yesterday against the fence and cut it. He had not applied any first aid and the cut was uncovered. I encouraged John to make an appointment with his GP to have it looked at, he declined.
  • Appetite, meals and diet eg. John had not eaten the dinner I left for him yesterday afternoon. I cleaned out the fridge today as there was out of date food and several uneaten meals. John said he hadn't felt like eating much recently.
  • Goals progress e.g Today I supported Mary to signup for a painting class at the local community centre. She has been regularly saying she wants to meet new people and make friends in her area and she would love to learn to paint.
  • Hazards and safety e.g The garden tap on the left hand side of the house is leaking making the path continually wet and a slip hazard.

*For things such as roster changes, call back requests, taking time off please do not use checkout notes for this function. Contact the Care Team via the details in the app.

Using appropriate language to write a checkout note

  • It is important to keep in mind checkout notes are part of a persons health record and may be read by health professionals or auditors.

  • Notes should be objective and factual, concise, appropriate in language, professional and respectful. Objective writing is based on facts and observations. It is a description of what actually happened. Subjective writing is based on or influenced by the writer’s point of view, emotions, assumptions, speculation, judgement or interpretations

  • Try to use phrases like - I noticed, I watched, I observed, I found, I identified, I witnessed, I saw, I monitored.

  • AVOID phrases like - I believe, I presume, I felt, I thought, I suppose, I guessed, I figured.

  • Language should be simple but appropriate and not include slang unless recording a Member's exact words.

  • Emoji's are not appropriate to use in checkout notes.

  • Use language appropriate to the Member's age. If supporting an adult don't say 'I changed John's nappy' but rather say 'I assisted John to change his incontinence aid'. Don't say 'John had a tantrum about the TV and stormed off' but rather say 'John yelled for several minutes and expressed he was upset about the TV being broken. He closed his bedroom door and requested I stay outside his room, he remained in there alone for 10minutes to have some time and space to himself'.

  • Be respectful. Imagine it was yourself or your loved one the note was about and how you would like your personal information shared with others.

What happens after I submit by checkout note?

Five Good Friends receive over 13 000 checkout notes each month. Not every note is manually read by a person and we utilise the power of Lookout to analyse the notes and escalate to the Care Manager which notes require follow-up. This allows us to focus our energy on where help is most needed.

If a matter is urgent and needs to be addressed immediately then please contact the Care Team immediately. After the matter is safely resolved, make sure you still document what happened in the note and if appropriate complete an incident form .

What difference can a note make?

  • Reporting changes in behaviour/mood and cognition can lead to: GP review, mental health care plan, counselling, increased visits from helpers or family and friends. Increased funding if eligible.
  • Reporting changes in pain/mobility/hazards can lead to: Physio sessions for falls prevention and strength balance exercises. OT Assessment, falls alarm, pain management and medication review by GP 
  • Changes in appetite/weight loss can lead to: Clinical review from Community Nurse, Meal delivery service or extra visits for meal prep
  • Reporting happy stories/great visits: Helps build a baseline for the Member and we can also share these with family and friends via our Shared Notebook feature in the App.

Examples of great check-out note stories

  • Mary’s story – Helper Kate reported in her checkout note that Mary, who is legally blind, was missing medications as she couldn’t see them clearly. The Care Manager arranged for a tablet timer where all mediations are now stored in a separate compartment and a timer alerts when they are due. Mary was able to continue administering her medications independently and safely.

  • Claire's story – Helper Sarah wrote in her checkout note Claire was experiencing pain in her side. This alerted in real time to the Care Manager who then organised for another helper to visit in the afternoon and take her to the GP. When the Helper arrived Claire's health had deteriorated further and the Helper called an ambulance. Claire was admitted to hospital and received swift treatment. Claire is now home and recovering. Sarah’s detailed checkout completed in real time allowed the Care Manager to intervene early and resulted in the best outcome for Claire.

Remember as a Helper you are the eyes and ears in a Members home, your notes are important and make a real difference in the quality of care. We use them, we act on them and we are grateful for your efforts in recording them.