Progress notes are the ongoing written record of care: what happened at a visit, what changed, and what was done. They may use SOAP, DAR, narrative or a provider's own template, but they must still let someone who was not there reconstruct the visit later.
Quick Definition
Progress notes are timed entries in the client record that describe care as it happens. They sit beside the care plan and together they show whether planned services were delivered and how the person responded.
Common Formats
SOAP (Subjective, Objective, Assessment, Plan), DAR (Data, Action, Response) and free narrative are the three formats most often compared in aged care. Providers should standardise on one primary format so audit sampling stays consistent. Governa's comparison of progress note formats sets out when each fits.
Home Care Reality
In Support at Home the note is often written from a client's kitchen table by a lone worker. Same-shift completion matters: a note written days later is weaker evidence. Declined services, no-access visits and escalations need explicit lines, not silence.
Related Terms
See SOAP notes, DAR charting, clinical documentation and client record. For visit-level requirements under Support at Home, read home care documentation requirements on the Governa blog.
Frequently Asked Questions
Are progress notes the same as a care plan?
No. The care plan sets what should happen. Progress notes record what did happen and how the person presented.
How soon should a visit note be written?
As close to the visit as practical, ideally before the worker leaves the shift. Delayed notes are a common audit weakness.
Related Resources
This entry is general guidance for aged care and home care teams, not legal advice.
