How to write care notes, with examples

The rule most managers quote is "if it isn’t written down, it didn’t happen". That is not just a saying. Providers registered with the Care Quality Commission are required by Regulation 17 of the 2014 regulations to:

Contemporaneous means written at the time or as soon as practical afterwards. Accurate means what you saw and did, not what usually happens. Complete means the gaps matter as much as the entries: a missing evening note on the night someone fell is the first thing an investigator will notice.

Good notes also do a quieter job. They let the next worker pick up where you left off, they show a pattern before it becomes a crisis, and they protect you. A clear note written at 14:10 is a far better defence than a memory of a visit three weeks ago.

Whatever system you use, paper or app, a complete note answers the same seven questions.

• When: date, arrival time and departure time. If you are writing later, record the time of the care and the time of writing.
• Who: your name or initials, and anyone else present, such as a family member or a district nurse.
• What care was given: each task from the care plan, and anything on the plan that was not done, with the reason.
• How the person was: mood, appetite, mobility, skin, pain, in plain words, compared with what is normal for them.
• What they said: their own words in quotation marks where it matters, especially about pain, worries or choices.
• Anything different: a new mark, a missed meal, a change in behaviour, a visitor, a fault with equipment.
• What you did about it and who you told: the action, the time, and the name of the person you reported to.

If nothing changed, say what you checked rather than "no change". "Skin intact on heels and sacrum, checked during personal care" tells the next reader something. "All fine" tells them nothing.

The most common weakness in care notes is opinion dressed as fact. "Was being difficult" is a judgement. "Pushed the plate away twice and said she was not hungry" is what happened, and it lets a nurse or a manager form their own view. Stick to three habits.

• Describe behaviour, not character. Say what the person did, for how long, and what was happening around them.
• Use their words. "Said: my hip is agony when I stand" is evidence. "Complained of pain" is a summary that has lost the detail a GP needs.
• Be specific with amounts and times. "Drank about 200ml of tea and half a glass of water" beats "drank well". "Repositioned at 22:00 and 02:00" beats "turned regularly".

Avoid abbreviations unless your service has an approved list, and never invent your own. A family member reading "pt c/o SOB, obs NAD" has no idea whether to worry.

The people in these examples are fictional. Each pair shows a note as it is often written, then the same visit written so that a colleague, a family member or an inspector could rely on it.

A morning home care visit, before: "Personal care done, breakfast given, meds prompted, all fine."

After: "09:05 to 09:50. Supported Margaret with a strip wash at the sink as she chose not to shower today, said she felt cold. Skin on heels and sacrum checked, intact. Dressed in clothes she picked. Breakfast: porridge, ate about half, and a full mug of tea. Prompted 09:30 medication from the blister pack, taken and observed. Margaret in good spirits, talked about her daughter visiting Sunday. Left with the TV on and her walker beside the chair."

A meal declined in a care home, before: "Refused lunch again. Being difficult."

After: "12:40. Offered fish pie, then a sandwich as an alternative. Frank declined both, said: I’m not hungry, my stomach feels off. Drank half a glass of squash. This is the second lunch declined this week (also Tuesday). No vomiting or loose stools reported by night staff. Reported to senior carer Priya at 12:55, who will monitor at tea and inform the nurse if he declines again."

A fall, before: "Found on floor in bedroom, helped up, seems ok."

After: "15:20. Heard a call for help and found Joan sitting on the bedroom floor beside the bed, facing the window. She said she had stood to close the curtain and her knee gave way. No head injury reported, no visible injury, no pain on gentle movement of arms and legs. Did not lift: called the senior, who assessed and used the hoist to return her to the chair at 15:35. Observations taken by the nurse. Fall incident form completed. Daughter informed by phone at 16:10. Sensor mat requested."

A change in mood, before: "Low mood today, didn’t want to talk."

After: "18:30. Dev was quiet throughout the visit and stayed in bed with the curtains drawn, which is unusual for him; he is normally up and watching the news. When asked how he was he said: no point getting up, is there. Declined the evening meal, drank a cup of tea. No mention of wanting to harm himself; I asked directly. Reported to the coordinator, Sam, at 18:50 for review, and noted for the GP who visits Thursday."

• Write as soon as you can after the care, not at the end of a run of visits. If you must write later, say so: "Written 17:30 for the 14:00 visit."
• Never leave a gap. If a visit was missed or cut short, record that and why.
• Correct mistakes without hiding them. On paper, a single line through the error, initialled and dated. In an app, use the edit function; the system keeps the original. Never use correction fluid and never delete.
• Assume the person will read it. Under UK GDPR they have a right of access to their records, and families and advocates often do read them. Write about people the way you would speak to them.
• Keep it to the point. A good note is usually four to eight lines. Length is not thoroughness; detail is.

Many care workers now paste a rough note into ChatGPT or a similar app to tidy the grammar or turn bullet points into sentences. The instinct is right: a rushed note written at the end of a double shift often needs help. The problem is that the note contains the person’s name, address, health conditions and sometimes a family member’s details, and all of that leaves your organisation the moment you press send. Our guide on ChatGPT and case notes explains why that is a data protection breach, not a grey area.

The safe way to do it is to take the personal details out first. Caredact does this automatically: paste the rough note, and names, addresses, NHS numbers and care identifiers are detected and replaced with labelled placeholders. You check the highlights and mark anything it missed, the AI tidies the checked version, and the finished note comes back with the real details in place. Only the version you checked goes to the AI, and there is a record of each step.

Two rules apply whichever tool you use. The note is still yours: check every line of the tidied version against what actually happened, because an AI will happily smooth "ate about half" into "ate well". And never let it add anything you did not observe. AI can fix your sentences. It cannot fix a note that was not accurate to begin with.