Document
Keep your attention on the care encounter.
Record the conversation and clearly state your own findings and agreed actions.
Hysio Care and Wellbeing Support Worker
After washing, dressing or a meal, you say what you did and saw. Hysio organises it into a short, factual report.
A structured report in your professional terminology
From care encounter to report
Hysio turns spoken information into a report. Choose the report format for the conversation you are documenting.
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Record the conversation and clearly state your own findings and agreed actions.
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State relevant information, your own findings and agreed actions aloud so you can find them in your report.
The information appears under the headings of your chosen report format, so you can review each section.
Check names, facts and agreed actions. Edit the text where needed before using the report in your records.
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Quick answer
Three documentation formats for support workers: a single care moment, a focused observation and the handover to the next shift.
In short, how Hysio works for support workers. You read every note back and decide what goes into the record.
The profile contains three documentation formats. The Hysio Support Worker Care Encounter Report describes one completed supportive care moment. The Hysio Support Worker ADL & Wellbeing Observation is for a focused observation. The Hysio Support Worker Shift Handover informs the next shift about one client. Choose based on the purpose of your note; in every format, what the client reports, your own observations, the help provided and open agreements stay recognisably separate. With voice-driven reporting, after a care moment you describe what you did and saw; Hysio organises it in the chosen format and you read the note through before you use it. [3] [4] [5]
The care encounter report describes what the client reports, what you observe yourself, which support was actually provided and how the client responded. The agreed follow-up is kept separate. Hysio does not add a cause, diagnosis or new care plan. An action that was only prepared or requested is not described as carried out. You check the note before you use it. [3]
This documentation format describes one focused observation moment during daily support. You record the reason, activity, concrete observations and client response. State what the client did independently and which help was provided. Hysio does not turn visible behaviour into a diagnosis or a judgement about self-reliance. Any flagging of concerns and any follow-up agreements only go into the report when you have provided them. [4]
A shift handover describes the current situation of one client for the next shift. Relevant events, support provided and open actions stay separate. State who picks up an action and when, if this has been agreed. Hysio does not set its own priority. Preparing the text also does not prove that the next shift has received the information or accepted the task. [5]
Describe which support you actually gave and what the client did independently. Keep a wish or request from the client separate from what was carried out. Include the response when it was reported or observed. Hysio organises this as one care moment and does not derive a new care need or plan change from it. Check whether the text correctly reflects the help provided. [3]
State the reason for and the moment of the observation. Describe concretely what you saw, heard or measured according to the instructions, with the correct quantities and units. Keep what the client reports separate from that. Hysio does not draw a conclusion about a cause or nutritional risk. Only record feedback or a follow-up agreement when it has actually been made. [4]
The Hysio Support Worker Shift Handover is set up for one client and one internal shift change. Provide the information separately for each client. Hysio should not split up a whole shift's worth of information by itself or decide which client has priority. For this handover, include the relevant events and open actions, and check before use that no information about anyone else has crept in. [5]
Preparing, offering and actually supporting are different steps. State which step took place, for example whether clothing was only laid out or whether you also helped with dressing. Hysio must not infer from a preparation that something was carried out. Also check the response: it only goes into the report when the client reported it or you observed it. [3]
For care and wellbeing support workers, Starter costs €20 per month, Pro €40 and Unlimited €80, excl. VAT. Pay per year and you get two months free. The price does not vary by care moment or documentation format. The support worker assesses the text for factual observation and local agreements; Hysio does not decide what is transferred to the record. [6]
Only use information that is needed for the agreed support and follow your organisation's privacy agreements. Discuss who gets access to a report about ADL, wellbeing or behaviour, and which data may be shared with others. A family member being present at the contact does not automatically give access to the report. The privacy policy describes the division of roles at Hysio. [8]
A support worker provides support within the existing plan and the instructions given. You describe which help you provided and flag changes to a responsible colleague. In doing so, you do not independently establish a diagnosis, needs assessment or treatment plan. In the report, keep your own observation separate from a judgement or instruction given by someone else involved. [11] [12] [14]
In an emergency where postponing care is not possible, everyone is expected to act to the best of their knowledge and ability as long as no better care is available. Afterwards, describe factually what you found, what you did and who was alerted. Keep your own observations separate from information from others. The emergency is not a general extension of your normal authority. [13]
Helpende Plus is an elective module for additional care tasks, such as measuring vital signs, support with compression stockings and certain forms of medication administration. Recognising deviations in the client is also part of it. The elective module was developed for staff at level 2, including in home care. In a care report, describe the procedure that was actually carried out; the name of the training alone does not say what happened during this care moment. [14]
No, the role of support worker does not give independent authority for reserved procedures. Carrying them out on instruction is subject to conditions, including competence and the agreements about instruction and, where necessary, supervision or intervention. Follow the care plan and your organisation's task agreements. In the report, describe what you actually carried out; text in the record does not make a procedure authorised after the fact. [13]
Write concretely what you see or hear and when it happens. A client who interrupts an activity is not automatically described as unmotivated or confused. Hysio does not add such explanations. A term used by a responsible colleague can, however, be recorded with its source. Keep that statement separate from your own observation and the support provided. [4]
Name the action, the person responsible and the agreed moment, as far as these are known. An open question stays open and is not turned into a task by Hysio. The report should also not suggest acceptance by the next shift. Check which actions have already been carried out and which still need to be discussed or followed up. [5]
Record what was different during the care moment and what you base that comparison on. Keep the client's words separate from what you saw or heard yourself. Describe which help you provided and to whom you passed something on. Hysio does not add an explanation or risk assessment; the responsible colleague assesses which next step is needed. [3]
An observation report describes one focused observation, with reason, observation and response. A shift handover has a different recipient and purpose: informing the next shift about the current situation and open actions. Information from an observation can appear in it if you provide it. The observation format itself is therefore not a replacement for a complete handover. [4] [5]
When you write it yourself, you create the record note directly. When you dictate, you first provide the information about the care moment; Hysio helps to organise it. Admin with AI takes over the typing, but the checking stays with you. Compare whether reports, observations and help provided are reflected correctly and whether the next colleague understands the note. [9]
The trial lasts two weeks. Use a made-up care moment, for example, to see whether the text clearly shows what help you gave and what the client did themselves. Also try an observation during a meal and a short shift handover. Notice how much you need to change before the note is right. [7]
Not automatically. For a medical record under the WGBO (Dutch Medical Treatment Contracts Act), a minimum of twenty years from the last change applies in principle, and sometimes longer. A support worker may also report in other forms of care or support. The rules for the record in question are therefore decisive. Follow your organisation's retention instructions instead of applying one period to all notes yourself. [16] [11] [12]
The Wet BIG governs, among other things, who may carry out reserved procedures independently or on instruction. The role of support worker does not give independent authority for this. When carrying them out on instruction, competence and the conditions around instruction, supervision and intervention matter, among other things. A report describes how the procedure was carried out, but does not replace the agreements that must apply to the procedure in advance. [13]
With a care provider that falls under the Wkkgz (Dutch Healthcare Quality, Complaints and Disputes Act), you must be able to report incidents safely within the organisation. That way colleagues can discuss what happened and learn from it. A daily care note and an internal incident report each have their own purpose. Use your organisation's agreed route for reporting; simply noting something in the care report does not automatically count as a report via that route. [15]
Describe what the client indicated themselves about, for example, the meal or how the day is spent. Keep a wish separate from an agreed action or support already provided. Hysio does not turn a preference into a new instruction for the next shift. If a wish still needs to be discussed, that stays visible and no decision or task acceptance is added. [5]
No. The care encounter report describes one completed supportive contact. It does not independently assess whether care goals have been achieved or whether the plan needs to change. An explicit judgement by a responsible colleague stays with that source. If the contact concerns only a care plan evaluation, this documentation format does not fit. Use the route your organisation has agreed for evaluation and plan changes. [3]
Describe which action the client carried out independently during this observation moment and where support was needed. Include the situation and the help actually provided. Hysio must not derive a general score or judgement about self-reliance from this. A concrete observation during dressing does not automatically say anything about all daily activities without further assessment. [4]
State what you passed on, to whom and when this happened. Keep this separate from feedback that is still outstanding. Hysio should not describe a plan to alert a colleague as a notification that has already been made. Also check that advice or an instruction from that colleague is reflected correctly and does not appear as your own assessment. [5]
The Hysio Support Worker Care Encounter Report is intended to record a separate supportive care moment: your observations, the care provided, the response and the agreed follow-up. The Hysio Support Worker Shift Handover is intended for informing the next shift about the current situation and what still needs to happen. Information from a care moment can be relevant there, but the purpose of the report differs. The support worker checks which information is needed. [3]
First check whether the text describes the right client, the care moment and the support actually provided. Only transfer the passage you have reviewed and that is needed according to your organisation's agreements. A prepared report does not prove that it is already in the record. Check the current capabilities and way of working of any integration separately. [10] [9]
Read the whole report before you use it. Check whether the support provided, the client's own choices and a change you observed are correctly reflected. A remark from a loved one must stay recognisable as coming from that person. Add missing information yourself and check whether follow-up agreements match what was actually agreed. [9]
No. An internal shift handover is a text for the next shift. NEN 7545 describes requirements for systems for electronic data exchange between nurse specialists, nurses and carers. That does not automatically make a support worker's report a technical eOverdracht message. Check your organisation's exchange route; a readable report does not prove a technical connection or compliance with that standard. [18]
Only record what was actually measured according to your instructions and task agreements. Include the value, unit and moment, and do not add your own medical explanation. Vital sign measurements are covered in, among other things, the elective module Helpende Plus. The name of the training alone does not prove which procedure was carried out during this contact or which instruction applied to it. [14] [11] [12]
Show both moments separately with their date or time and the corresponding source. Only explicitly comparable data may be placed side by side. Hysio does not calculate a trend, difference score or cause. If a responsible colleague assesses a change, that assessment stays with the colleague. Check that the text is not more definite than the two observations allow. [4]
State when an event or report took place and where that information comes from. An older report does not automatically become the situation at this shift change. Hysio only uses what has been provided for this client and handover. State what is now confirmed or still unknown, so that the next colleague does not read outdated information as current. [5]
Yes, if the report is relevant to this care moment and stays recognisable as coming from the loved one. Do not write as if you saw it yourself. The care encounter report distinguishes such information from your observations and the help actually provided. Only include what is needed for the support and check that the attribution is also kept in the summary. [3]
Then the response stays unknown. Hysio must not infer from silence that the client is satisfied, gives consent or has no complaints. Do describe what was actually observed and which help was provided. If a response matters for the follow-up, it must be checked according to the working agreements and only then added as confirmed information. [4]
Not automatically. The text can contain an explicitly agreed action owner and deadline, but does not prove that anyone has heard or accepted the task. Hysio does not assign tasks. So check the status of open actions and follow the agreements for the actual handover. Keep a request, an accepted task and a completed action apart. [5]
Use a recognisable source, for example that the client tells you something or that you saw something yourself. A report about the night is not your own observation if you were not present. Hysio keeps both types of information separate. Then describe the support you provided yourself and the follow-up that was actually agreed. [3]
Compare the incorrect passage with your original information and only change what you can substantiate. Then check whether the same error also appears in the summary, response or follow-up agreement. A correction must not add a new assumption. Read the full report again before you use it and follow your organisation's record agreements if a note has already been transferred. [9]
Do not guess words, values or actions. Listen back to the passage in question if possible, or check the information with the right person involved. Voice-driven admin only works well if it stays visible what is still uncertain. Something the client reported must not be filled in as your own observation. [9]
According to CBS, employees in health and social care spent on average 31 per cent of their working time on administration in the second quarter of 2025, including documentation and registration. It is a sector figure and not a Hysio measurement. It also does not show how much time an individual support worker can save. For that, you need to look at your own work separately. [19]
The duty to report lies with the care provider that falls under the Wkkgz. An established calamity must be reported to the IGJ (Dutch Health and Youth Care Inspectorate) within three working days. That is a different route from a support worker's daily reporting. Follow the agreed internal reporting procedure and describe factually what happened; writing a record note alone does not replace the organisation-wide report. [15]
With the infographic 'Goed geregeld?' (Well organised?), ActiZ shows which laws and regulations apply to the sector and describes the bureaucracy in care as excessive. That concerns the organisation of elderly care and is not an extra list of fields for every report by a support worker. Use such sector information to discuss the registration burden. In an individual report, record what is needed for the support and the agreed follow-up. [21]
No. The CBS figure of on average 31 per cent administrative time in 2025 concerns employees in the health and social care sector. It does not automatically describe the working day of every support worker. Tasks, work setting and agreements can differ. Use a sector figure to understand the wider context and assess the registration burden in your own work separately, without deriving a promise of savings from it. [19]
If the source states that a measurement was carried out but gives no result, it stays explicitly unknown. Hysio should not choose a normal value or guess an outcome. A measurement that was only announced does not yet count as carried out. Check the result with the right source before you add it to the observation yourself. [4]
Check whether events, reports and instructions keep their correct source and status. An action that has been prepared has not yet been carried out, and an open question is not a decision. Hysio does not determine urgency or a new monitoring frequency. Only include agreements that were actually made and show what has not yet been confirmed, so that the next shift does not build on an assumption. [5]
Describe what the client indicated themselves after the support and what you directly saw or heard. Keep those sources recognisable. Hysio can record the order of help and response, but does not add an explanation or causal link. A statement by a responsible colleague can be included separately if it is relevant and clearly labelled as such. [3]
No. The observation format describes concrete observations, what the client reports and the support provided. It does not assign a diagnosis, risk, urgency or score. A term that a nurse or doctor explicitly uses can be included with its source when relevant. Hysio must not derive that term from behaviour itself or attach a new instruction to it. [4]
Compare similar care moments and measure the whole process: recording information, reviewing the text, correcting it and transferring it. Besides time, also assess whether reports, observations and follow-up agreements are correct and understandable. AI reporting only pays off if you have less to correct. Do not derive personal savings from a general sector figure. [9]
Start with a few fictitious or suitably chosen practice cases and agree who checks the text. Review the available capabilities, privacy agreements and way of working for the record in advance. Compare the output with what was actually provided and discuss unclear passages. Only use the platform according to your organisation's agreements; a successful example does not replace those agreements. [9] [8]
Hysio creates the report. You remain responsible for what you save in the record.