A Four-Step Workflow for Care Progress Notes
Capture observations, draft a structured note, review it and record it using your organisation's configured process. This is one of seven practical workflows in AccuNote.
Explore all seven modulesThe 4-Step Care Note Workflow
From the care moment to a completed progress note.
Select Person
Select the person you're documenting for and refer to the information available in your configured workflow.
- Refer to available person and care context
- Complete picture of current care plan
- Mobile ready on any device
Resident Selection
Documentation Method
Speak or Type Your Observations
Capture observations using the input options available to your team, such as templates, freeform entry or dictation. Review the draft for accuracy and context.
- Smart templates for quick documentation
- Dictation option for hands-free entry
- Freeform typing with smart suggestions
Review & Enhance
Review the drafted note for accuracy and context. Standards feedback can help guide the review, but does not certify compliance or replace professional judgement.
- Review the draft before using the note
- Real-time suggestions for quality
- Standards feedback to support staff review
Smart Editing & Review
Note Submitted & Saved
Record the Note
After review, record or transfer the note using the process configured by your organisation. Staff remain responsible for the final record.
- Follow your organisation's recording process
- Keep responsibility for the final record with staff
- Follow your organisation's record-keeping requirements
What Happens While You Document
AccuNote can assist with drafting and surface feedback for staff to consider before they use or record a note.
Standards Feedback for Staff Review
AccuNote can provide standards-related feedback to support documentation review. Staff should check the record and decide what action is appropriate.
- Standards-related feedback
- Quality metrics
- Prompts to support staff review
Documentation for Follow-up
Managers can use documentation views to identify records for follow-up. AccuNote does not certify audit readiness or provider compliance.
- Complete audit trails
- Review workflows and records
- Evidence collection