Guides · For support workers
How to write a support note
What a progress note is for, what goes in it, when it's an incident instead, and what the people who read your notes are actually looking for. From fifteen years of writing them at the end of a shift.
Every note you write has four readers. The worker on the next shift. Your team leader. The auditor or the funder, months later. And the person the note is about, who has the right to read it any time they ask. Write for the first and the last of those, and the two in the middle look after themselves.
That's the whole guide in two sentences. The rest is how.
The bones
Five things every note needs.
- When and who. Date, shift, your name. The system usually stamps it, but check.
- What happened. What you saw and heard. Times where they matter.
- What you did. The support you gave, and anything from the plan you used.
- How the person responded. In their words where you can.
- What the next shift needs to know. One line, at the end. More on that below.
If the note has those five, it's a good note. If it's missing the last one, the next worker starts the day blind, and that's the gap most notes have.
The one rule
Write what you saw, not what you decided.
"Sam was being difficult" is a judgement. "Sam pushed his plate away, said he wasn't hungry, and went to his room" is what happened. The second one is useful to the next worker, fair to Sam, and defensible in front of anyone. The first one is none of those.
The same goes for words like aggressive, manipulative, non-compliant, attention-seeking. They feel like shorthand. They read as a verdict on the person, written into a record that outlives you. Say what the person did and what they said, and let the reader draw the conclusion.
The person's own words are the most valuable thing you can put in a note. Ngā Paerewa, the standard every certified service is audited against, asks for the person's perspective and wishes in their record. A quote does that in one line.
What stays out
Four things that don't belong in a note.
- Diagnoses you're not qualified to make. "He seemed low" is fine. "He is depressed" is a clinician's call.
- Other people's information. Another resident's name, a family member's health, a colleague's private life. Each person's record is theirs.
- Your opinion of a colleague. That goes to your team leader, not into a client's file.
- Anything you couldn't read to the person across a table. Because you may have to. They can ask for their record, and the answer is yes.
Hard to read isn't the same as unfair. A note that says someone hit you is hard to read and belongs there. A note that calls them a name doesn't.
Incident or note?
When it's an incident, it's both.
Some things go in the note and on an incident form, and the form has a clock on it. An injury. A medication error, including a missed dose. Any restraint. A person missing. Anything that looks like abuse or neglect, from anyone. Police, ambulance, hospital. A death. If you're not sure whether it counts, it counts, and your team leader would rather hear about it twice than not at all.
The order is act, tell, write. Make the person safe, ring who you need to ring, then write it down while it's fresh. Your service's policy sets the timeframe for the form. Behind that sits the contract: a residential service on a Disability Support Services contract has to notify some events within 24 or 48 hours, and the time on your note is where that clock starts.
In the note itself, an incident reads like any other event: what happened, what you did, how the person is now, and that the form was completed. No drama, no defence. The form carries the detail.
The handover line
One line for the person walking in at seven.
Finish every note with the one thing the next shift needs. Not a summary of your shift. The thing they'd want to know before they say good morning.
- "For the morning: she wants a shower before the van, and she's asked to ring her mum on Saturday."
- "Bin night. He's said he'll take them out himself if someone reminds him at 6."
- "Sore left foot since the walk. Check it before shoes go on."
If your service does verbal handover, say the same line out loud. Written is the one that survives a sick day.
Who reads it, and for what
What the other readers are looking for.
- The NASC, at review. Whether the goals in the person's plan are moving. Name the goal when a note touches it: "worked on the bus route to the library, goal 2". That sentence is evidence at the next review.
- The auditor. That notes are current, dated and signed, that the plan is being followed, and that incidents were actioned. They don't read for style. They read for gaps.
- The funder. Counts, mostly. Bed nights, exits, incidents by type. Your note feeds the count; it doesn't need to explain it.
- The person. Whether they were seen. Their words in the record, their choices respected on the page even where you disagreed.
Records are kept for at least ten years after the last contact. Someone will read your note long after you've forgotten the shift. Write it so that reader, whoever they are, can see the person and not just the paperwork.
Dictating
If you talk your notes instead of typing them.
More services are letting workers dictate notes, and some now use a tool that tidies the dictation into a note. Same rules apply, with two more. Read every word back before you sign, because a tidying tool will happily turn "he pushed the plate away" into "he was aggressive" and you're responsible for the words, not the tool. And keep the person's information on work devices only. Never a personal phone, however handy it is at 11pm.
Before and after
The same shift, written twice.
Before. "3 to 11. Went okay. Sam was in a mood at dinner. Watched TV. Bed 9."
After. "3 to 11. Sam ate half his dinner (sausages, left the veg) and said he wasn't hungry. Watched the rugby, laughed at the ref, said 'that's a penalty, ref'. Declined his shower, said tomorrow morning instead, and I agreed. In bed by 9:10, asleep at the 9:30 check. For the morning: he wants the shower before day programme, and he asked to ring his mum on Saturday."
Same shift, thirty seconds more. The second one tells the morning worker what to do, shows the NASC that Sam makes his own choices, and reads fine if Sam asks to see it.
Source Ngā Paerewa Health and Disability Services Standard NZS 8134:2021, Ministry of Health
Source Sector guidance for Ngā Paerewa, Ministry of Health
Source Health Information Privacy Code 2020, Office of the Privacy Commissioner
Source Code of Health and Disability Services Consumers’ Rights, Health and Disability Commissioner
Source Health (Retention of Health Information) Regulations 1996
Source Community Residential Support Services service specification, Disability Support Services
Last checked 21 September 2026
General guidance from one support worker's experience, not your organisation's policy. Your service's own policies and your team leader come first; where they say something different, follow them.
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Hand this page to new staff, put it in the induction pack, or ask Jamie to run it as a session with your team. Fifteen years on the floor, most of them writing notes at 10:45pm. Email jamie@neurosupport.co.nz.