This is Part 10 of the Tea and Care series, Care Principles Made Simple.
Care notes may look like routine paperwork, but they can directly affect someone’s safety, dignity and continuity of care. They tell other staff what happened, what changed, what the person chose and what action was taken.
A useful care note allows someone who was not present to understand the situation clearly. A poor note leaves them guessing.
A small detail that mattered
Imagine a care worker supporting Mr Lewis at lunchtime.
He normally finishes most of his meal, but today he eats only three spoonfuls. He says he feels sick, drinks a small amount of water and appears paler than usual.
A vague note might say:
Mr Lewis was not himself today. Did not eat much.
This suggests that something changed, but it does not provide enough information for the next worker to judge what happened.
A clearer note might say:
12:40 pm — Mr Lewis ate approximately three spoonfuls of lunch and drank around 150 ml of water. He said, “I feel sick.” He appeared paler than usual and declined dessert. The senior carer was informed at 12:50 pm and agreed to continue monitoring him.
The second note records what was observed, what Mr Lewis said, what support was offered and who was informed.
If the same thing happens again later, staff can recognise a possible pattern and respond appropriately.
Care notes are part of care
Writing notes is not separate from providing care. It supports:
- Safe handovers between workers
- Recognition of changes in health or behaviour
- Consistent support across different shifts
- Respect for choices, preferences and refusals
- Communication with managers and professionals
- Review of care plans and risk assessments
- Investigation of accidents, complaints or safeguarding concerns
- Evidence of the care and support provided
This connects directly with your duty of care. If you notice something important, recording and reporting it helps other people act on that information.
In England, CQC Regulation 17 requires providers to maintain secure records that are accurate, complete and contemporaneous.
“Contemporaneous” simply means recorded at the time of the event or as soon afterwards as reasonably possible.
The Skills for Care Code of Conduct also expects care workers to maintain clear and accurate records and report changes or concerns promptly.
What makes a good care note?
A good care note should be:
Timely
Complete the record during the shift and as close to the event as possible. Waiting until much later increases the chance of forgetting important details.
Never enter a false time or make an entry appear as though it was written earlier. If a late entry is necessary, follow your organisation’s procedure and identify it honestly as a late entry.
Factual
Record what you saw, heard, did or were told. Avoid guessing someone’s motives or making unsupported conclusions.
Instead of:
Mrs Khan was being difficult and refused to cooperate.
Write:
Mrs Khan declined support with showering at 8:15 am and said, “I would like to do it after breakfast.” Her choice was respected, and support was offered again at 10:00 am.
The second version records the person’s decision without judging them.
Clear
Use straightforward language that another worker can understand. Avoid unexplained abbreviations, vague phrases or language that could have several meanings.
“Settled” may mean different things to different people. Describe what you actually observed.
Complete
Include enough information to explain what happened, but do not fill the record with irrelevant details.
Where relevant, record:
- The date and time
- The care or support offered
- What was completed
- What the person did independently
- Any choices, preferences or refusals
- Relevant observations
- Changes from the person’s usual presentation
- What the person said
- Action taken
- Who was informed and when
- The outcome or planned follow-up
Person-centred
Care notes should reflect the person, not only the tasks completed.
Instead of writing:
Personal care done. Breakfast given.
You could write:
Ms Green chose a blue dress and completed her face washing independently. Support was provided with washing her back and lower legs. She chose porridge with banana for breakfast and ate approximately three-quarters.
This records ability, choice and participation. It supports the same principles discussed in Person-Centred Care in Plain English.
Secure
Care records contain personal and health information. Only access information required for your work and use approved systems.
Follow your employer’s rules about:
- Passwords and individual login details
- Locking screens and signing out
- Storing paper records securely
- Sharing information with authorised people
- Using work devices
- Disposing of confidential documents
- Reporting lost information or data breaches
Do not photograph care records on a personal telephone or discuss them in public places. Our guide to confidentiality in care explains these responsibilities further.
Describe behaviour instead of attaching labels
Words such as “aggressive,” “challenging,” “attention-seeking” or “confused” can be unclear and judgmental when they appear without supporting detail.
Describe what happened instead.
Rather than:
Mr Patel became aggressive.
Write:
At 4:20 pm, Mr Patel raised his voice, pushed his chair away from the table and said, “Leave me alone.” Staff stepped back, reduced noise in the room and offered him space. He appeared calmer after approximately 10 minutes.
This gives the next worker useful information about the behaviour, possible triggers and the response that helped.
If you include an opinion, make it clear that it is an opinion and explain what it is based on. The ICO’s accuracy guidance advises organisations to distinguish opinions from facts and to identify whose opinion is being recorded where appropriate.
Record refusals properly
Adults may refuse care, food, medication or another form of support. A refusal should not automatically be described as non-compliance.
Record:
- What was offered
- How it was explained
- What the person said or did
- Any alternative offered
- Whether risks were discussed
- Who was informed
- Any action required by the care plan or workplace procedure
For example:
At 9:00 am, Mr Owens declined support with shaving and said he did not want to shave today. His choice was respected. No immediate risk was identified.
If a refusal creates a significant risk, follow the care plan and report it promptly. Do not pressure the person simply to make the record look complete. The principles of mental capacity and consent still apply.
Record changes and escalate concerns
A written note does not replace speaking to the appropriate person when something requires urgent action.
If you notice a significant change, report it immediately according to your organisation’s procedures. This may include changes in:
- Breathing
- Consciousness or alertness
- Mobility
- Eating or drinking
- Skin condition
- Pain
- Continence
- Mood or behaviour
- Medication response
- Communication
- Risk of harm
Record what you observed, who you contacted, when you contacted them and any instructions received.
In an emergency, obtain help first. Complete the necessary records after the person is safe.
Care notes do not replace other reports
An everyday care note may not be the only record required.
Depending on the situation, you may also need to complete:
- An accident or incident form
- A body map
- A safeguarding report
- A medication record
- A falls record
- A food or fluid chart
- A behaviour-monitoring chart
- A communication or handover record
Follow your employer’s agreed procedures. Recording an incident in daily notes does not necessarily replace reporting it through the correct safeguarding or incident system.
If you suspect abuse, neglect or improper treatment, follow the reporting steps explained in Safeguarding Explained Simply.
Medication records need particular care
Medication administration records must accurately show what was administered, refused, omitted or unavailable.
Never sign to confirm that medicine was administered if you did not administer or directly witness it as required by your procedure. If you make an error or discover a missing entry, report it immediately and follow your organisation’s medication policy.
CQC guidance states that adult social care providers must maintain secure, accurate and up-to-date medication records for each person receiving medication support.
Only administer or record medication when you have the appropriate training, assessed competence and authorisation.
Correct mistakes honestly
Do not secretly delete, overwrite, backdate or disguise a mistake.
For paper records, follow your organisation’s correction procedure. This commonly involves leaving the original information readable, adding the correction and recording the date, time and your identification.
Electronic systems may retain an audit trail showing who entered or changed information.
If you discover inaccurate information, report it and follow the proper correction process. The aim is for the record to show both what happened and how the mistake was addressed.
Data-protection rules also require personal information to be accurate and updated where necessary. People can request the correction of inaccurate personal data through the right to rectification.
Avoid copying yesterday’s note
Copying and pasting an earlier entry may save time, but it can create inaccurate records.
A person’s appetite, mood, mobility, skin condition, choices and support needs can change. Every entry should reflect what happened during that particular visit or shift.
Templates and electronic prompts can help you remember important areas, but they should not replace observation and professional judgement.
Remember that the person may read it
Care records are about a real person, not a collection of tasks.
Write respectfully and professionally. Ask yourself:
- Is this accurate?
- Is it necessary?
- Is it respectful?
- Have I separated facts from opinions?
- Would I be comfortable explaining this entry to the person?
- Could another worker understand what happened?
- Have I reported anything that requires action?
The 2025 Care Certificate standards include handling information among the knowledge and skills expected in health and social care roles. Skills for Care also provides learning on the principles of professional record keeping.
The simplest rule
Write what happened, not what you assume happened.
Include the person’s choices, the support provided, any relevant change and the action taken. Record it promptly, store it securely and report concerns through the correct channel.
Accurate care notes protect the person, support colleagues and create a reliable picture of care over time. They are not “just paperwork.” They are part of safe, respectful and accountable care.
This article provides general information about adult social care in England. Workers should follow their employer’s policies, care plans, training and agreed ways of working. Requirements may differ in other UK nations.
This concludes the 10-part Tea and Care series, Care Principles Made Simple.
