Daily care record

What you need to know

The plain-English guidance that comes with this document.

• Write it at the time, and write it true. Daily notes are the running story of someone's care — what happened, how they were, what changed. Done at the time they're accurate; done from memory at the end of a shift they're not. If it wasn't recorded, in practice it didn't happen.
• Facts and observations, not opinions or shorthand you'd be ashamed of. Write what you saw and did ("ate half of lunch, declined the rest", "walked to the lounge with one carer") — not vague or disrespectful labels. Assume the person or their family may one day read it, because they can.
• Changes are the point — and some need acting on, not just noting. A skin mark, a fall, eating less, low mood, confusion, a refusal — record it, and report the urgent ones straight away rather than leaving them in the book for the next shift to find. The note is a record; it isn't the alarm.
• Food, fluids and mood matter. Poor eating and drinking, and changes in mood or behaviour, are early warnings of illness, pain or decline. A few honest words each visit build a picture that catches problems early.
• It's confidential care data. Store it securely, share only with those who need it. In domiciliary care, think about what's left in the person's home versus held securely by the agency.
• Professionally structured starting point — adapt it. A registered manager sets how notes are kept and checked in your setting; it's not "compliant out of the box".
• Applies UK-wide. Accurate, contemporaneous records are expected by all four nations' regulators (CQC, CIW, Care Inspectorate, RQIA).