Assistant in Nursing (AIN) Progress Notes: Real Examples & What to Document

Last updated 2026 · SupportNotes · Made in Australia

What is an AIN progress note — and why does it matter so much?

A progress note is your short written record of what happened with a resident or client during your shift — what you observed, what care you gave, and anything you reported to the registered nurse (RN) or enrolled nurse (EN). It is part of the person's clinical record, which means it is a legal document. If anyone ever asks 'what happened to Mr Nguyen on Tuesday afternoon?', your note is the answer.

You are often the person who spends the most time with each resident. You shower them, help them eat, walk beside them, and notice when something is 'just not right' today. That puts you in a powerful position: your notes are frequently the first place a small change in someone's health gets written down. A good note can be the reason a deteriorating resident gets seen early.

Under the Aged Care Quality Standards (in residential and home aged care) and the NDIS Practice Standards (in disability support), the provider has to be able to show that care was delivered, that changes were noticed, and that risks were acted on. Your progress notes are a big part of how the organisation proves that. You don't need to memorise the standards — you just need to write clearly, factually and on time.

What should an AIN document on every shift?

You are not expected to write a diagnosis or a care plan — that's the RN's job. Your job is to record what you did and what you observed. A simple way to remember it: write what you'd want the next carer (and the RN) to know before they walk into that room.

• ADLs (activities of daily living): showering, dressing, grooming, toileting, continence care, and how much help the person needed (independent, supervision, assistance of one, assistance of two).
• Eating and drinking: what and how much they ate and drank, appetite, any refusal, swallowing concerns, and fluids if you're tracking intake.
• Mobility and transfers: how they moved, equipment used (hoist, walker, slide sheet), any unsteadiness, near-miss or fall.
• Vitals you actually took: temperature, pulse, BP, oxygen sats, blood glucose, weight — with the numbers and the time.
• Skin and pressure areas: redness, broken skin, bruising, repositioning done.
• Mood, behaviour and sleep: settled, anxious, withdrawn, agitated, confused, slept well or restless — described by what you saw or heard.
• Pain or discomfort: what the person said, where, and what you did (e.g. repositioned, told the RN).
• Anything you escalated: what you noticed, who you told (name and role), and when.
• Your sign-off: full name, role (AIN), and the time you wrote the note.

What should an AIN NOT write in a progress note?

Just as important as what to include is what to leave out. Staying inside your scope keeps you and the person safe, and keeps the record trustworthy.

• Don't diagnose. Write 'skin red and warm over left hip' — not 'resident has a pressure injury' or 'looks like an infection'. Describe; don't label.
• Don't guess or assume. If you didn't see it, don't write it as fact. 'Found on floor beside bed' is honest; 'tripped on the mat' is a guess unless you saw it.
• Don't write opinions or judgements about the person. 'Refused shower, said he was tired' — not 'being difficult' or 'attention-seeking'.
• Don't leave blanks or use vague words. 'Had a good day' tells the RN nothing. Say what made it good.
• Don't backdate, white-out, or write for someone else. Correct an error by ruling a single line through it, writing the correction, and initialling — never erase.
• Don't record other people's care under your name. Only document what you personally did or saw.

Before & after: real AIN note examples

Here is the part that actually changes your notes. Each example shows a rough, rushed note (the kind written in 10 seconds at the end of a busy shift) and an audit-ready version that an RN, an auditor, or a family member could rely on. Notice the audit-ready notes are still short — they're just specific, factual and signed.

How to escalate: when 'tell the RN' goes in the note

Escalation is where AIN notes save lives, so make it visible in writing. Whenever you notice a change — a raised temperature, a fall, a refusal to eat two meals in a row, new confusion, breathlessness, a change in skin, or a resident who is 'just not themselves' — your job is to report it up, not to manage it alone.

The golden rule: if you reported it, write it down — and if you didn't write it down, it's hard to prove you reported it. Always record what you noticed, who you told (their name and role), and the exact time. 'Reported to RN Sarah at 1245' is one short line that protects everyone.

If you raise something and you're worried it hasn't been acted on, escalate again to the next person up — and note that too. Speaking up is part of your duty of care, and a clear written trail is what backs you up later.

5 quick rules for fast, audit-ready notes

You don't have time to write essays at the end of a 10-hour shift. You need notes that are quick to write and still hold up. These five habits do that.

• Be objective: write what you saw, heard, and did — not what you think it means.
• Be specific: numbers, times, amounts and equipment beat vague words like 'good', 'fine' or 'a lot'.
• Write it on shift: note it while it's fresh, not from memory the next day. Late entries lose detail and trust.
• Name names: who you told, their role, and when. Escalation only counts if it's recorded.
• Sign every entry: your full name, 'AIN', and the time. No initials-only mystery notes.

Writing notes when English is your second language

A huge number of brilliant AINs across Australia speak English as a second or third language, and worrying about grammar can make note-writing stressful. Here's the good news: clear and simple beats fancy every time. Auditors and RNs want facts, not poetry.

Short sentences are perfectly professional. 'Mr Brown ate half his lunch. Drank one cup of tea. Reported low intake to RN Anna at 1pm.' — that is a great note. You do not need long words or complicated grammar. Stick to what happened, in the order it happened.

Keep a small list of the words your workplace uses (ADLs, repositioned, assistance of one, intake, escalated) and reuse them. If you're ever unsure how to word something, describe it the way you'd explain it out loud to a colleague — that plain version is almost always the right one to write down.

Write better notes in less time

Good documentation isn't about writing more — it's about writing the right things, clearly, every time. If you turn the rough notes in your head into the audit-ready versions above, you protect your resident, your team and your own registration.

Want a faster way to do it on a busy shift? Try the free progress-note helper at our home page. Type in a few rough words about your shift — what you did, what you saw, who you told — and get a clean, factual, plain-English note you can check, tweak and use. It's built for AINs, it's free, and it works just as well if English is your second language.

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