ACCURATE NOTE TAKING

ACCURATE NOTE TAKING

When you take notes during a visit it’s important that your notes are accurate. Every evaluation should be substantiated with your documentation. Good documentation provides accountability for you.

When is it necessary to have good notes?

• When you discussing an issue with provider that must be address and changed.

Ex: Provider must be more accurate and timely when making out her attendance sheets.

• When you are investigating a complaint against provider.

• When you are investigating a complaint from the provider against a parent or other employee.

• When you see a noncompliance issue or a dangerous situation.

BE OBJECTIVE

Your note taking should be objective, reporting what you see, hear, or smell. You should never record an assumption, or draw a conclusion without documenting the reasons why. You may make the note that the kitchen smells bad, but you need to list the facts that drew you to that conclusion.

For example: The trash was overflowing with a soiled diaper on the top. There was garbage and dirty dishes in the sink. Never base a written conclusion based on your personal feelings or relationship with a provider.

Don’t ignore your ‘gut’ feeling. Sometimes we may have the feeling that something is not right. We may feel uncomfortable but not be able to identify what is causing the feeling by your observation. When you have concerns, don’t ignore them but go to your supervisor and discuss your concerns. Be care of what you put in writing in the provider’s file. Be careful of putting anything in your written documents you are not able to substantiate.

STANDARD OF NOTE TAKING

It’s helpful when you develop a standard method for note taking. Here are some tips to do that:

• Always start with the provider’s name and the date of visit at the top of each page.

• Standardize punctuation, abbreviations, and margins. Make your original notes legible enough so you can read them later.

• If you are using a tablet or laptop, use abbreviations of your own when possible. When in doubt, write the word out.

• Take and keep notes in a notebook. The effort required to recopy notes from loose papers is better spent rereading and thinking about them. Remember to leave some blank spaces. White space between topics gives you room to fill in additional points later.

• Write with ink. Use pen, not pencil, for permanency. Draw sketches when necessary. This can be especially helpful when you are attempting to convey the layout or floor plan of a child care setting.

• Complete all notes as soon as possible after conducting home visits. You should make every attempt to document when information is fresh in your mind. On any given day you may make several visits. Keeping your documentation organized is especially important when you are visiting multiple homes in one day.

Remember what you “think” or “feel” is not relevant in your written notes. The important thing to remember is to document what you “see”. Your assessment can have serious consequences on a provider’s ability to operate their child care business. It is essential that you make a clear, concise chronology based on your observations at the time of the visit.