NDIS progress notes and shift notes, with a free template

The NDIA's record keeping requirements say every record you keep, notes included, should show:

• the participant's name
• their NDIS number
• the date or dates you delivered the support
• how much you delivered, such as the hours
• the support type.

A case note, it says, outlines what the participant did and how it relates to the specific support item and their goals, and can include their progress and plans for the next session. Missing records matter: if the NDIA reviews a claim and the records aren't complete, the money may have to be paid back.

• Write what you saw, heard and did. The NDIS Commission's advice for recording an incident is to record what you saw and any actions you took, and to leave out your opinions and interpretations. It holds for every note: instead of “Sam was lazy today”, write “Sam stayed in bed until 10am and said he was tired.”
• Use their words. When something matters, write what they said, in quotation marks.
• Tie it to their goals. Name the goal the shift was about and what moved, even a little.
• Be specific. Times, places and amounts beat “good shift”.
• Concerns: what you saw, what you did, who you told, and when. If someone may have been harmed, get help first and write it down after. The Commission's guidance says any allegation of a criminal offence against a person with disability must be reported to the police.
• Write it the same day, while you remember, and keep it about the participant and the shift, in plain words their family would follow.

One note per shift, written the same day. Write what you saw, heard and did, in plain words, with their own words where it matters. Copy it into whatever you write in, download it for Word, or print the PDF, one sheet a shift, and fill it in by hand. The note headings are the ones George's own notes use: the goal, then what happened, the participant's response, concerns and follow-ups.

Invented participants, written the way this guide suggests.

You may be asked for a progress report before a participant's plan review. The NDIA's guide to report writing says it should sum up the goals you're working towards, the supports you delivered, the progress made, any challenges and risks and how they're being handled, and the supports you'd recommend next. You give it to the participant, who can share it at their plan reassessment, or, with their consent, you can upload it through the provider portals.

A report is only as good as the notes it's written from, which is the best reason to write them well.

• They're health information. The privacy regulator (the OAIC) says health services include those given in the course of caring for a person with a disability, lists disability service providers that handle health information among the providers the Privacy Act covers, and says the Act covers a health service provider whatever its turnover. Health information is sensitive information, with stricter rules.
• Share them only with people the participant has agreed can see them, and keep them somewhere locked: not a shared family computer, an open email thread or a group chat.
• Keep them with the invoices they back up. The government says providers will need to keep records of NDIS payments for 7 years, with a penalty for not keeping them.

The OAIC recommends that organisations don't put personal information, and especially sensitive information, into publicly available AI tools, because of the privacy risks. If you use one anyway, take out names and anything that identifies the person first, check every word it gives back, and remember the note is your record, not the tool's.

Writing notes in George

George sorts what you type into the headings above and keeps every word as you typed it. With no signal, it holds the note on your phone until you're back online. A note locks after 24 hours so it can't be quietly changed: a correction is added, never an edit. Your notes become the progress report for a plan review, goal by goal. If you switch them on in Settings, George can type out a voice memo, and suggest tidier wording with the names it knows swapped out on your phone first, showing every change for you to accept or not.

Invoicing the shift too? See how to invoice the NDIS.