Care Notes Audit Checklist – Domiciliary Care

Use this Care Notes Audit for domiciliary care to review daily records for accuracy, consent & person-centred detail. For quarterly audits or monthly spot checks.

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Domiciliary Care (In-Home Care)
Care Notes Audit Checklist – Domiciliary Care

Completion & Timeliness

Content & Person-Centred Detail

Accuracy & Professional Standards

Sign-Off & Governance

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Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

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Care Notes Audit Checklist – Domiciliary Care

Use this Care Notes Audit for domiciliary care to review daily records for accuracy, consent & person-centred detail. For quarterly audits or monthly spot checks.

1. Are care notes completed for every scheduled visit?

2. Are notes available where visits did not take place (e.g., service user at appointment, cancelled visit)?

3. Does each entry record the correct date and time of the visit?

4. Are early, late, or missed visits explained and documented?

5. Is the time spent with the client recorded accurately (e.g., 10:05, not “10 am”)?

1. Do care notes describe the care tasks carried out during the visit?

2. Do the notes confirm whether all planned tasks were completed, with any additional information recorded?

3. Do the notes include the service user’s health and welfare observations?

4. Are mood, behaviour, and participation levels recorded where relevant?

5. Is fluid and nutritional intake, offerings, and choices documented?

6. Is medication given (including PRN) recorded where relevant?

7. Are refusals, concerns, accidents, or incidents recorded with actions taken?

8. Is evidence of consent for care documented?

1. Are the notes detailed, clear, and easy to understand?

2. Where handwritten, are the notes legible and completed in blue or black ink?

3. Where electronic, are the notes written appropriately without slang or text-style wording?

1. Is each entry signed or initialled by the staff member providing care?

2. Are additional monitoring forms completed when required?

3. Are care notes filed or stored securely within the care plan (digital or paper)?

4. Are the notes consistent with the service user’s care plan and support needs?

5. Do the notes provide sufficient information to evidence safe and person-centred care delivery?