Notes are an important part of the medication record. They provide context that the outcome code alone cannot convey.
Notes are mandatory for outcome codes 3 to 8 (Refused, Omitted, Missed, Made Available, Given by Family, and Other). For Code 1 (Taken) and Code 2 (Double Verified), notes are optional but can be added if needed.
Good notes are:
Factual and objective ("Supported person stated they felt sick" not "Supported person was being difficult")
Include relevant details (who was informed, what action was taken)
Written at the time, not from memory hours later
Notes are part of the permanent medication record and may be reviewed during CQC inspections, safeguarding investigations, or complaints.
Tips
- Keep notes professional. They may be read by inspectors, family members, or solicitors.
- In Round Mode, a notes dialog appears automatically for non-given outcomes (Refused, Missed, etc.).
- If you need to record a lot of detail, consider also adding a note in the supported person's daily care notes.