Continued Care: Entering and Viewing Shift Notes

Shift notes serve as a facility log for users to document relevant events and information during their shifts. For example, an overnight technician in a residential facility may record completed tasks, unfinished tasks, or critical updates for the incoming morning staff. Reviewing shift notes at the start of a shift ensures continuity of care by providing a timeline of past events.

Important: Shift notes are not part of a patient’s medical record. They facilitate communication between staff members across shifts and should never contain personal health information (PHI). Always refer to patients using initials or medical record numbers instead of full names.

Required Permissions: Admin, Nurse, Doctor, Tech, Case Manager, Therapist, Biller, Records Admin, or Super Admin

Best Practice Workflow Video

Best Practice Workflow Steps 

Let's review Kipu EMR's best practice workflows to enter and view shift notes. 

1. Click on Shifts in the header. The system automatically opens to the Shift Reports tab.
2. Click on New Report to begin documenting the shift.
3. Enter relevant details, including completed tasks, pending tasks, and significant events. Document the timeline of events and required follow-up actions using free text.
4. Attach any necessary files and click Save Report.
   
5. The system will display the shifts report in chronological order. You can filter by date range or use the Search field to find specific keywords in past notes.

Best Practices: At the start of a shift, reviewing shift notes helps maintain awareness of key events and pending tasks. If patient-specific reports are required, document them in a group session note or an evaluation form using Centralized Documentation to keep them in the medical record. For notes kept outside the medical record, use the Shift Notes section, referencing patients by MR number or patient ID rather than full names, and avoid using shift notes for individual patient documentation.