Daily Notes Requirements

Daily notes tell the story of each participant's day at your center. Good documentation supports compliance, informs care decisions, and keeps families connected. Here's what to include and how to do it efficiently.

Purpose of Daily Notes

• Track participant status and changes day to day
• Document services provided for billing support
• Communicate with families about their loved one's day
• Identify patterns that inform care planning
• Create record for regulatory compliance
• Support continuity when staff changes

Core Documentation Elements

Every daily note should capture:

• Attendance: Arrival and departure times
• General status: Overall mood, energy level, engagement
• Activities: Programs participated in and response
• Meals: What was served, intake, any concerns
• Health observations: Vital signs if taken, any symptoms or complaints
• Incidents: Falls, behaviors, medical events
• Communications: Contacts with family, doctors, case managers

ADHC-Specific Requirements

Adult Day Health Care centers have additional clinical documentation:

• Nursing assessments and observations
• Medication administration records
• Vital signs per care plan schedule
• Clinical interventions provided
• Therapy services delivered
• Changes in condition

Activity Documentation

Document activities beyond just listing what happened:

• Which activities the participant joined
• Level of participation (active, passive, refused)
• Response and enjoyment observed
• Connection to care plan goals when applicable
• Any adaptations made for the participant

What Triggers More Detailed Notes

Some situations require more thorough documentation:

• Any fall or near-fall
• Behavioral incidents
• Medical symptoms (dizziness, chest pain, confusion)
• Significant change from baseline
• Medication errors or refusals
• Family concerns or complaints
• Injuries discovered

Efficient Documentation Practices

Make daily notes sustainable:

• Document throughout the day, not all at once at the end
• Use templates with standard sections
• Allow selection from common observations
• Make narrative entry easy for exceptions
• Don't duplicate—if it's in attendance, don't re-enter in notes
• Train staff on "what's worth documenting"

Common Documentation Gaps

Watch for these common issues:

• Notes that are copy-paste identical day after day
• Missing documentation for absent participants
• No note when participant leaves early
• Activity notes that list activities without participation info
• Health observations without follow-up documented
• Unsigned or undated notes

Using Notes for Family Communication

Daily notes can inform family updates:

• Share highlights of the day at pickup
• Flag anything families should know
• Use notes to prepare for care conferences
• Some systems allow family portal access to appropriate notes