Aged Care Progress Note Examples: 15 Real Entries You Can Copy
Last updated 2026 · SupportNotes · Made in Australia
A good aged care progress note is factual, objective, dated and timed, written soon after the event, and signed with your name and role. Write what you saw, what you did, and how the resident responded — never your opinion or guesses. Below are 15 copy-ready examples (personal care, falls, mood, mealtime, incidents and more), each shown as a rough note turned into an audit-ready one you can adapt to your shift.
What makes a good aged care progress note?
You finish a busy shift, you are tired, and you still have notes to write. You want to get them right so the next worker knows what happened and so the note holds up if a manager, family member or assessor ever reads it back. The good news: a strong progress note follows a simple, repeatable shape.
A progress note is a factual record of care — what happened with a resident during your shift, what you did, and how they responded. It is part of the resident's clinical record, so write it as if someone who was not there needs to understand it months later. Under the Aged Care Quality Standards, accurate records support safe, coordinated care and your provider's duty to keep clear, current information about each person.
- Factual and objective — what you saw and heard, not what you assumed or felt
- Dated and timed — use the 24-hour clock (e.g. 1430) so the timeline is clear
- Specific — names, amounts, body parts, exact words in quotes where it matters
- Action + response — what you did and how the resident reacted to it
- Written soon after the event, while it is fresh and accurate
- Signed off — your full name and role, no blank gaps left in the record
The simple formula: Observed - Action - Response
If English is not your first language, or you just want a reliable pattern, use three short parts in every note. Many workers know this as a SOAP-style or 'OAR' approach: Observed, Action, Response.
Start with what you observed (the facts), then what action you took, then how the resident responded. Keep sentences short. You do not need fancy words — clear plain English beats clever writing every time.
- Observed: 'Resident found sitting on bedroom floor next to bed at 0640.'
- Action: 'Did not move resident. Checked for pain and injury. Notified RN immediately.'
- Response: 'Resident alert, said "I slipped". No visible injury. RN attended at 0648.'
Personal care progress note examples
Personal care notes get skipped or written too vaguely ('shower given'). Record what level of help the resident needed and anything you noticed about their skin, mood or ability — small changes here are often the first sign something is shifting.
- Rough: 'Showered, all good.' → Audit-ready: '0815 — Assisted Mrs P with shower. Required full assistance with washing back and lower legs, completed upper body herself. Skin intact, no redness observed. In good spirits, chatted about her grandchildren. — J. Okafor, PCW.'
- Rough: 'Refused care.' → Audit-ready: '0720 — Mr D declined morning shower, stating "I'm too cold today". Offered again at 0900, accepted a warm towel wash. Cooperative once room was warmer. Will reoffer shower this afternoon. — M. Tran, AIN.'
- Rough: 'Continence done.' → Audit-ready: '1100 — Provided continence support, changed pad (moderately wet). Perineal skin pink, no breakdown. Resident comfortable afterward, no pain reported. — S. Bayross, PCW.'
Falls and incident progress note examples
Falls and incidents are the notes most likely to be reviewed later, so they matter most. Never write that you 'picked the resident up' before an RN has assessed them, and never guess the cause. Record the facts, your immediate actions, who you notified, and the time of each step.
If your service is also covered by the NDIS Practice Standards for a younger resident, the same rule applies: factual incident records support your reportable-incident obligations. Stick to what you witnessed.
- Rough: 'Found on floor, helped back to bed.' → Audit-ready: '0305 — On rounds, found Mrs L lying on floor at bedside. Did not move her. Checked for visible injury — small graze to right elbow, no bleeding. RN notified immediately at 0306, attended 0309. Neuro and pain checks commenced by RN. Mrs L stated "I tripped on the mat". — R. Okonkwo, PCW.'
- Rough: 'Hit her head, ok now.' → Audit-ready: '1915 — Witnessed Mr T strike head on bedrail while transferring. RN notified at once. Head-injury observations started per RN. Mr T alert, no loss of consciousness observed, complained of mild pain to forehead. Family and RN updated. Incident form completed. — C. Shea, AIN.'
- Rough: 'Skin tear.' → Audit-ready: '1430 — Noticed skin tear approx 2cm to back of Mr H's left hand during personal care. Cause unknown. Pressure applied, RN notified at 1432 for wound review. Mr H reported no pain. — H. Bowen, PCW.'
Mood, behaviour and mental health note examples
These notes are easy to get wrong because we slip into opinion ('was difficult', 'attention-seeking'). Describe the behaviour you saw, the possible trigger, what you tried, and whether it helped. Use the resident's own words in quotes where you can.
- Rough: 'Agitated and aggressive all afternoon.' → Audit-ready: '1500 — Mrs B became distressed, pacing the corridor and calling out "I need to go home". Appeared to start after lunch noise settled. Offered reassurance, walked with her to the garden, played her favourite music. Settled by 1530, returned to lounge calmly. — P. Raghavan, PCW.'
- Rough: 'Very flat today.' → Audit-ready: '1015 — Mr F quieter than usual, declined to join morning activity, said "not in the mood". Ate half of morning tea. Sat with him 10 mins, encouraged a short walk which he accepted. Mood lifted slightly afterward. Will monitor and inform RN at handover. — D. Petrakos, PCW.'
- Rough: 'Wandering again.' → Audit-ready: '0240 — Mrs G awake and walking in corridor, looking for the bathroom. Oriented her, assisted to toilet, then settled back to bed with a warm drink. Asleep by 0300. — Y. Osman, AIN.'
Mealtime, hydration and weight note examples
Mealtime notes feed straight into nutrition and hydration monitoring, which assessors look at closely. Record amounts as fractions or measures, note any choking or swallowing concern, and flag refusals so the next shift follows up.
- Rough: 'Ate well.' → Audit-ready: '1230 — Mrs C ate full main meal and dessert at lunch independently. Drank one full glass of cordial. No coughing or swallowing difficulty observed. — A. Merrick, PCW.'
- Rough: 'Didn't eat much.' → Audit-ready: '1240 — Mr S ate approx 1/4 of lunch, said "not hungry". Encouraged fluids — drank half a glass of water. Offered a supplement drink, accepted. Poor intake noted; RN informed at 1300 for review. — B. Fairweather, PCW.'
- Rough: 'Coughing at dinner.' → Audit-ready: '1815 — Mrs W coughed twice while drinking thin fluids at dinner. Encouraged small sips, sat upright. RN notified at 1817 re possible swallowing concern. Speech pathology referral to be discussed. — T. Marinakis, AIN.'
Common mistakes that fail an audit (and quick fixes)
Most weak notes are not wrong on purpose — they are rushed. Here are the slips that get flagged in audits and family complaints, and the fast fix for each. Fixing these takes seconds once it becomes habit.
- Vague words — 'good day', 'fine', 'as usual'. Fix: state what you actually saw and any amounts.
- Opinions and labels — 'lazy', 'attention-seeking', 'aggressive'. Fix: describe the behaviour, not the judgement.
- No time — 'this morning'. Fix: use the 24-hour clock for every entry.
- Late or end-of-shift batch notes — Fix: jot key facts during the shift, write up promptly while accurate.
- Blaming or guessing cause — Fix: write 'cause unknown' rather than inventing one.
- No signature or role — Fix: always end with your full name and role; never leave blank lines in the record.
- Correcting by scribbling out — Fix: follow your service's correction policy (single line, initial, date) — never erase or use white-out.
Turn any rough note into an audit-ready one — free
If you ever stare at the screen unsure how to phrase something, you do not have to do it alone. Our free progress note helper turns a few rough words from your shift into a clean, factual, audit-ready note in the Observed–Action–Response shape — in plain English, ready for you to check and sign.
It is built for aged care and disability workers on real shifts: night staff, casuals, and anyone who writes in their second language. You stay in control — you read it, fix anything, and put your own name to it. Try it free at the link below and see how much faster end-of-shift notes can feel.
Frequently asked questions
How long should an aged care progress note be?
Long enough to be clear, short enough to read fast — usually two to five sentences. Cover what you observed, what you did, and how the resident responded. A fall or incident note will be longer because you record each step and the times you notified the RN.
Can I write my opinion in a progress note?
No. Progress notes are factual records. Instead of 'she was difficult', write what you actually saw, such as 'declined care and said she wanted to be left alone'. Describe behaviour, not judgements. Use the resident's own words in quotes where it helps.
What tense should I use?
Write in past tense for completed events ('assisted with shower', 'RN notified at 0641') and keep it objective. Avoid casual shorthand that the next worker or an assessor might misread.
Do I need to record the time on every note?
Yes. Date and time every entry, ideally using the 24-hour clock (e.g. 1430). For falls and incidents, record the time of each action too — when you found the resident, when you notified the RN, and when they were assessed.
What do I do if I make a mistake in a note?
Follow your service's correction policy. Generally you draw a single line through the error, write the correction, then add your initials and the date. Never erase, scribble out completely, or use white-out — the original record must stay readable.
Are these examples compliant with the Aged Care Quality Standards?
These examples follow good documentation practice that supports accurate, current clinical records — which the Aged Care Quality Standards expect. Always follow your own provider's documentation policy and templates, as wording and required fields can vary between services.
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