Session notes

Session notes must be written up for every session with a Member.
They must be done in the Lively app as part of 'checking out' of a session.
They must be written in the final 5 mins of the session (In the unlikely scenario this is not possible, then they must be completed within 12 hours).

The purpose of session notes:

Primary purpose:
- Keep track of progress with member towards their priorities.
- Keep good information flow for Coordinators and for any handover.
- Flag anything urgent for a member.
- Ensure your activities are well-documented in case anything goes wrong.
The secondary purpose is to provide any subjective and interesting insights into key activities with a member.
Sending a picture is not required as part of a session note, but can be a nice way of complementing your notes.

Structure

Writing your session notes should take less than 5 minutes. Aim for 2 minutes. You should write in concise sentences (not flowing prose), for each of the dot points below. Using objective language and the active voice ("We did this" rather than "This was done"), you should write:

The activities that happened that day. For this bit, stay objective, and aim to write at least 3–5 sentences about your activities.
- Where possible, try and link the activities to a member's expressed request or goal, e.g. "Member A had mentioned last week that he would like to pot some pansies this week, so we started with this," or, "We mopped the floors, as per Member B's regular request."
- Mention any incidents that may have occurred. You should also report these using the Incidents & Complaints form or by contacting Lively HQ.
Your plans for your next visit.
- Avoid writing "Same as usual", and be a little explicit, even if you have repetitive tasks for each session, e.g. "Vacuuming, laundry, emptying the bins and a cup of tea at the end!"
- If you set your plans together with your member, it can be a great way of getting them excited about your next session together.
Opt: Any observations that you had about how the member is feeling, or changes in their condition. This is more of a subjective assessment on your part and should be filled in if you have observed any unusual changes in their mental or physical condition.
- Do not use this field to request actions from HQ—please do so by contacting directly.

Great Example

Activity: Rose and I worked together on cleaning out her pantry, checked the use-by dates and put out-of-date items in the compost as she expressed that she was keen to get her kitchen in order! We then created a list of items to replace and then created labels for the shelves and the items. She had a small fall during the visit when she tripped on her cat, but appeared uninjured.

Plans: Next we’re planning to visit the shops to restock her fridge and will create labels for the shelves and the items.

Observations: She mentioned that she was having some stiffness in her back and she appeared to me to be slightly bent over. I suggested that she might like to update her care plan to include some physiotherapy and said I’d ask her Care Manager to give her a call about that.

Tone

In addition to following the structure above, it's important that you write using a precise and objective tone, in full sentences and using proper punctuation. This is because your notes may need to be shared with family members, case managers or other people.

Here's an example of notes that are too subjective, and don't adopt correct grammar and punctuation:

i caught up with mary today she was pretty pushy about getting her windows washed so i focused on that which calmed her down she also got really stressed about when wed next meet up so we set up our next session then

The above notes could be corrected as follows:

I caught up with Mary today. She demonstrated some anxiety to get her windows cleaned, so I focused on that during the session, starting with the kitchen and living room. After I had done so, she expressed that she felt relieved to have the job done. She also appeared stressed about finding a time for our next session, so we set up our next catch-up at the end of our session for the same time next week.

Incident reporting

If an incident occurred during the session, in addition to noting it in your session notes, you should also follow Lively's incidents process. Remember, an incident is an unplanned event that caused or had the potential to cause illness, distress, injury, property damage or disruption of normal services as part of Lively’s programs or activities, especially where it leads to ongoing risk to any person or Lively as an organisation.

As outlined in the Incidents & Complaints section, usually this will mean reporting the incident to the appropriate Support Coordinator or Care Manager. If you're not sure whether something is an incident, play it safe and assume that it is!

Hot tips

Feeling awkward about doing your notes during the session?

Make it inclusive and reflect on the session together with the member as you write your notes:

What activities you both did that day
What your plans are for the next session

If there are any sensitive observations or incidents, add them straight after you leave.

What if the member challenges me about stopping early?

You can say, "Notes are an important part of Lively’s activities. For example, it helps us keep on track with our work and keeps our team Coordinator and team mates up-to-date with what is going on so we can support each other."

As a fall-back, you can say that it is Lively policy that notes are captured in the final 5 mins of a session.

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