Seizure & Bowel Care Documentation: What to Record (With Real Examples)

Last updated 2026 · SupportNotes · Made in Australia

Why does your documentation matter so much in high-intensity support?

If you work high-intensity or complex shifts, you already know the pressure. You might be the only person in the house at 2am when a seizure starts. You might be the one who notices a participant hasn't had a proper bowel movement in four days. In those moments, your hands are busy keeping someone safe. But the note you write afterwards is just as important as the support itself.

Here is the reason: your seizure and bowel records are not just "paperwork". They become part of the person's clinical picture. The GP, neurologist, continence nurse and behaviour support practitioner all read your notes to decide whether to change a medication, order a test, or adjust a plan. If your notes are vague, they are working blind. If your notes are clear, you might be the reason a doctor catches a problem early.

Under the NDIS Quality and Safeguards Commission's High Intensity Support Skills Descriptors, workers supporting epilepsy and complex bowel care are expected to monitor and record changes accurately, and to follow the person's individual management plan. Auditors check that this is actually happening in the daily records. So good documentation protects three people at once: the participant, you, and your provider.

What exactly should you record after a seizure?

Picture it from the doctor's side. They never saw the seizure. Everything they know comes from your note. So your job is to put them in the room with you. The strongest seizure records (often called a seizure chart or seizure log) capture the same details every time, so patterns become visible over weeks and months.

Here is what to record, in plain terms. Write the facts you observed, not your interpretation.

• Date and exact start time — "2:14am", not "early hours". Time is everything with seizures.
• What happened just before — any warning signs, aura, mood change, or trigger you noticed (missed sleep, missed dose, illness, flashing screen).
• Seizure type and what the body did — which side, eyes, jerking, stiffening, falling, lips going blue, loss of awareness, incontinence. Describe it, don't diagnose it.
• Duration — the time it STOPPED, so length is clear. Note if it lasted longer than usual or longer than the plan's threshold.
• Medication given — if you gave emergency/PRN medication (for example a midazolam preparation), record the drug, dose, route, time, and that you gave it per the person's plan and authorisation.
• Recovery — how they were afterwards: confused, drowsy, sore, agitated, vomiting, sleeping. Keep monitoring and note it.
• When they returned to baseline — and whether you called an ambulance, family, on-call nurse, or the manager (and the time you called).

What should a bowel care note actually say?

Bowel documentation gets neglected because it feels uncomfortable to write about. But for someone at risk of severe constipation, bowel obstruction or faecal incontinence, a missed pattern can become a medical emergency. Your note is the early-warning system.

The single biggest upgrade you can make is to stop writing "BO" or "bowels open" and start using the Bristol Stool Chart — a clinical scale from Type 1 (hard lumps) to Type 7 (entirely liquid), used right across Australian health and continence services. Recording the type turns a vague note into useful clinical data. Always follow the person's individual bowel care plan for what you do; your note records what happened.

• Date and time — and whether it was a scheduled intervention or a spontaneous movement.
• What you did — per the bowel care plan (for example assisted toileting, administered a prescribed laxative, suppository or enema as authorised). Never improvise outside the plan.
• The result — Bristol Stool Chart type (1-7), rough amount (small/moderate/large), and colour if relevant.
• Anything abnormal — blood, mucus, very dark or black stool, unusual smell, pain, straining, or no result at all.
• Change from this person's normal — e.g. "3 days since last bowel motion, plan threshold is 3 days". Knowing their baseline is the point.
• Action taken and who you told — followed the plan, notified the nurse/GP, and the time.

What is the difference between a rough note and an audit-ready one?

You don't need fancy words. English doesn't have to be perfect. Auditors and clinicians are not grading your grammar — they are checking whether the record is specific, timed, factual and tied to the plan. Here is the simple test before you submit a note.

• Specific, not vague: "Type 2, small amount, mild straining" beats "a bit constipated".
• Timed: real clock times for the event, any medication, and any phone call.
• Factual, not assumed: write what you saw and heard. "Lips pale" not "I think he stopped breathing". "Reported sore" not "in agony".
• Tied to the plan: show you followed the Epilepsy or Bowel Care Plan, and named the threshold that triggered your action.
• Signed and complete: your name, role, the date, and no blank fields. Don't leave gaps for someone to guess later.
• Written close to the time: memory fades fast. Jot key times immediately, then write it up properly as soon as the person is safe.

What do auditors and nurses actually look for?

When an NDIS audit or a clinical review looks at high-intensity records, they are not trying to catch you out. They are checking that the system around a vulnerable person is working. From talking to the standards and the way these reviews run, a few things come up again and again.

If you can answer "yes" to the points below for every seizure and bowel entry, your documentation is in strong shape.

• Is there a record EVERY time — including the events that 'seemed minor'? Missing entries are a bigger red flag than imperfect ones.
• Do the times line up across the seizure chart, the medication record (MAR) and the progress note? Contradictions get noticed.
• If PRN or emergency medication was given, is the reason recorded AND the outcome checked 30-45 minutes later?
• Is the person's individual plan being followed, and is the note specific enough to prove it?
• Are changes from baseline flagged and escalated to the right person, with the time?
• Is the language objective and respectful — describing the person with dignity, not labelling them?

A 60-second routine you can use on any shift

You are tired, it's the end of a long shift, and the note still has to be written. Use this simple order so you never miss a field. It works for both seizure and bowel entries.

Time → What I saw → What I did (per plan) → Result/recovery → Who I told. Five steps. Write them in that order and your note will already be most of the way to audit-ready.

If you'd like to make this faster, our free documentation helper walks you through these exact fields and turns your rough words into a clear, timed, plan-aligned note in seconds — so you spend less time on paperwork and more time on care. You can try it free at the link below. It never stores the participant's identity for you to worry about; you stay in control of the record.

Frequently asked questions