Document
Keep your attention on the care encounter.
Record the conversation and clearly state your own findings and agreed actions.
Hysio Individual Healthcare Carer
Hysio organises your care moment, your observation and your handover into a factual report, keeping what the client reports, what you observe, the care provided and agreements separate.
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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More attention for the conversation, less typing afterwards.
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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For your team
Quick answer
Three documentation formats for the care moment, the focused observation and the shift change.
Here is a brief overview of how Hysio writes up a care moment or observation. You read every report back before it goes into the EHR.
For individual healthcare carers there are 3 documentation formats: Care Encounter Report, Clinical & Behavioural Observation and Shift Handover. The layout follows the care moment itself. The Care Encounter Report covers one completed care moment. The Clinical & Behavioural Observation covers one focused observation moment, with context, observation and measurement. The Shift Handover covers the briefing about one client for the next shift. In all three, what the client reports, factual observation, care provided and agreements stay clearly separate, and the individual healthcare carer decides what goes into the record. [3] [4] [5] [1]
The Care Encounter Report turns a short spoken or typed account of one completed care moment into a factual journal entry. What the client reports, what you factually observed and measured, which care, support or medication was provided, how the client responded and what was agreed all stay clearly separate from each other. Anything missing or contradictory stays visible on its own. Hysio does not add any judgement, instruction or authority that you did not mention. [3]
The Clinical & Behavioural Observation organises a voice note about one focused observation moment into a factual observation report. The context of the observation, what the client reports, your own physical and behavioural observation, the exact measured values, the actions carried out and the reported follow-up each stay traceable on their own. A source term such as confused or restless stays as a statement by the person who used it. Hysio does not turn it into a diagnosis, risk assessment or explanation of behaviour. [4]
The Shift Handover organises the briefing about one client into a clear report for the next shift. You read the current situation, the care provided with medication and measurement facts, the client's response, the points of attention for the next shift and the open actions with the name of who picks them up. It concerns one client and one shift change within your own team, not a handover to another organisation. [5]
The Care Encounter Report fits when one care moment is completed and you dictate it straight afterwards: help with washing, dressing, eating and drinking, toileting, transfer or mobility. You describe what the client did themselves, where you took over and how the client responded. If it is not about care provided but about a focused observation, the Clinical & Behavioural Observation fits better. If the shift changes, the information belongs in the Shift Handover. [3]
The Clinical & Behavioural Observation keeps five types of information apart: what the client reports themselves, what you specifically see or hear, exact measured values with unit and time, which actions you carried out, and whom you reported something to with which agreed follow-up. In addition, place, time and reason record the context of the observation. If a value is missing or a sentence is unintelligible, it stays visible as an open point instead of being filled in. [4]
The Shift Handover fits the moment when you hand a client over to the colleague on the next shift, in the nursing home, the residential setting or the home setting. The report concerns one client and one shift change within your own team. It is not a formal handover across the care chain to another organisation: that requires record context, a recipient, authorisation and a validated data set. For a single care moment or a focused observation, the other two formats are more suitable. [5]
The section on care provided only contains what you named out loud: medicine, dose, unit, route of administration, time and who carried it out, insofar as you mention them. Hysio does not infer any administration, instruction, authority or competence from your professional title and does not fill in a missing dose. A nursing procedure that you explicitly mention stays as a source fact. If you do not mention a sign-off or a protocol, it does not appear in the report either. [3]
For an individual healthcare carer, Starter costs €20 per month, Pro €40 and Unlimited €80, excl. VAT. If you choose a year, you pay for ten months. The price is the same for a care moment, an observation or a shift handover. [6]
Start with the care goal: which information is needed for this client and this care moment. Set out who may listen in, read along, edit and approve, and follow your organisation's agreements about dictating in the client's home. Do not include information about housemates or other clients that does not belong to this care moment. At a care moment with the client, the individual healthcare carer decides what may be kept or shared; presence alone is not consent. [8]
eOverdracht is the information standard for formal handover between care providers. V&VN is the owner, Nictiz is the administrator, and the standard uses health and care information models (zorginformatiebouwstenen) with HL7 FHIR in the technical implementation. A shift handover within your own team is something else: it concerns one client and one shift change. The Hysio Shift Handover provides readable text and claims no information standard, no message set and no technical exchange. A genuine handover across the care chain requires record context, a recipient, authorisation and a validated data set. [20]
There is no fixed frequency. The qualification file for the individual healthcare carer does not name one, and the Generiek kompas places the obligation with the team and the organisation: advance care planning, medication incidents and attention to eating and drinking must demonstrably be discussed. How often that happens is agreed by your organisation itself. What you record counts as evidence: the outcome of a discussion and an open point both belong traceably in the record, with date and those involved. [18] [15]
With many changes in the team, continuity relies on what is written down, not on what was passed on verbally. Recording is not a side issue here: in nursing, care and home care, Statistics Netherlands (CBS) measured in the second quarter of 2025 that 17.5 per cent of working time went to documenting care and 10.0 per cent to recording for the organisation. These are sector figures, not a measurement of individual healthcare carers specifically. So make sure your observation, the care provided and the open point can be read back later. [12] [13] [16]
The two natural moments to document are a completed care moment and a focused observation moment; in addition there is the shift change. There is no national figure for the contact duration, contact frequency or reporting time of individual healthcare carers, so there is no external norm. What is established is the content of the work: basic care in personal care, eating and drinking, toileting, mobility and the sleep-wake rhythm. So choose your moment to document at the care moment itself, not by a clock that does not exist. [18]
Since January 2026, the IGJ (Health and Youth Care Inspectorate) has assessed care at home, in the neighbourhood and in the nursing home against one combined framework of standards. That framework replaces the older assessment framework for community nursing, so a community team and a nursing home team are measured against the same standards. In practice, this mainly means that your report must be traceable. Who observed something, when, what was carried out and what was agreed must be findable without anyone needing to ask you. [17]
The individual healthcare carer is an article 34 profession under the Wet BIG: the training title is protected, there is no individual registration in the BIG register and BIG disciplinary law does not apply. The nurse is an article 3 profession, with registration and disciplinary law. Both work in the same settings of nursing home care, care for people with disabilities and mental healthcare, often in the same team and around the same client, which blurs the difference in practice. In your report it does stay visible: you record a nursing diagnosis, indication or instruction with its source role and never attribute it to yourself. [13] [11]
The observation is what you saw or heard, with place, time, duration and frequency insofar as you state them. The interpretation remains yours. A word such as confused, restless or care-avoidant only appears in the report as a statement by the person who used it, stating who that was. Hysio does not expand such a term into a picture, does not determine urgency and does not choose a follow-up. Under follow-up, only what was actually reported and agreed is recorded. [4]
The points of attention for the next shift contain what your colleague really needs to know: a change you have seen, an agreed check, a planned procedure and the time at which something needs to be revisited. The open actions state who picks up what. A point that has not yet been answered stays open and is not quietly closed. Hysio does not set priorities, does not give instructions and does not attach urgency to anything you did not name. [5]
Writing yourself means you produce the final text during or just after the care moment: you choose the words and you are done straight away, but it often happens between two clients. Dictating first captures your own account; Hysio then organises it into the layout of the chosen documentation format. In both cases, the professional assessment stays with you. So do not only compare speed, but also faithfulness to the source, readability and how much you still adjust afterwards. [9]
You can try Hysio free for 14 days. Use those two weeks for a small number of comparable, made-up care moments rather than scattered trial runs; then you see a pattern and not a lucky hit. Follow your organisation's privacy agreements while trying it out too. Each time, note how long documenting took, what you adjusted and whether the text reflects the care moment correctly. [7]
That is the Richtlijn Verpleegkundige en verzorgende verslaglegging (guideline on nursing and care documentation) of Verpleegkundigen & Verzorgenden Nederland, the Richtlijn Verslaglegging for short. The guideline calls for unambiguous, traceable electronic documentation that fits the work situation. It does not prescribe a fixed heading structure: SOAP, SOEP and SBAR are not an obligation for your sector. The guideline uses client as the overarching term, with patient, resident and care recipient under it. If your setting explicitly uses resident, that word stays. [12] [13]
The Omaha System is a classification language for problem, intervention and outcome. According to several independent sources, it is used in more than 80 per cent of the electronic client records in Dutch community nursing. That makes it common in community care, but not mandatory nationally and not automatically applicable in the nursing home or in care for people with disabilities. Whether you work with it depends on your organisation and your record system. For your own text: describe in plain words what you saw, did and agreed. [22]
The zorgleefplan (care and living plan) organises the client record into four domains: physical wellbeing, mental wellbeing, housing and living conditions, and participation. That framework is widely used in nursing home and residential care and in home care for the record as a whole. It says nothing about the layout of your daily reporting beneath it; that can differ per organisation. So make sure you describe a care moment as it happened, and that placing it in a domain remains a choice for you or your organisation. [21] [22]
Since 1 July 2024, the Generiek kompas 'Samen werken aan kwaliteit van bestaan' (generic compass for quality of life) has been the applicable quality framework for long-term care. It replaces the older, sector-specific Kwaliteitskader Verpleeghuiszorg and applies more broadly than the nursing home alone. For your work, this mainly means that quality is accounted for through team discussions and demonstrable agreements. Your reporting provides the material for this: an observation, the care provided and the agreement made must each be findable separately. [18]
The Kwaliteitsregister V&V is a voluntary, periodic registration with requirements for continuing professional development. It is not a legal obligation and not a BIG registration either: as an individual healthcare carer you fall under article 34 of the Wet BIG and you are not in the BIG register. Re-registration requires you to be able to demonstrate training and work experience over the registration period. What you write in the client record is separate from that: it is care documentation and not proof of registration. [14]
For a client with a psychogeriatric condition or an intellectual disability, additional requirements apply to involuntary care: proportionality, subsidiarity, consultation with experts, a formal step-by-step plan and periodic evaluation. That assessment is a decision of the professionals involved, not of a documentation format. Hysio does not establish any legal status, does not classify any restriction of liberty and does not draw up a step-by-step plan. What you factually observed, carried out and reported, and what someone else explicitly decided, Hysio records with a note of who said it. [19]
With involuntary care, the record carries the accountability. If it remains unclear who decided which measure, on what grounds, with which alternative and when the evaluation followed, the care taken in the step-by-step plan is not demonstrable afterwards. For you this means: note the date and time, what you factually saw, which action was carried out, who was consulted about it and what was agreed. Leave out a conclusion that you are not able to substantiate yourself; an open point is more honest than an assumption. [19]
The three mandatory themes are advance care planning, medication incidents and attention to eating and drinking. The Generiek kompas turns them into assessable discussion topics, and since the new framework of standards of January 2026, not being able to show this is a concrete point of attention in IGJ supervision. If your reporting does not show that a medication incident was reported or that eating and drinking were discussed, that evidence is missing. So write down what was reported, to whom, and what was agreed afterwards. [17] [18] [21]
No. Hysio does not write directly to an electronic client record and makes no technical connection with your organisation's system. You get text that you read, correct and adopt yourself according to local agreements. With voice-driven admin too, you check whether you are pasting into the right record and field, and whether the date and time are correct. The individual healthcare carer remains responsible for what is saved. [10] [9]
Read the text alongside your own memory of the care moment, not as a stand-alone piece. Check four things: is the speaker right for every statement, is the time right, is every measured value noted with its unit, and was the next step really agreed that way. Anything missing or unclear you leave as an open point. With voice-driven reporting, Hysio organises the text; you correct and approve it before anything goes into the record. [9]
The Omaha System organises care along three axes. The problem, also called the area of concern, names what the care is about. The intervention describes what was done and with what intention. The outcome records how the situation afterwards relates to the starting point. In community nursing this language is common, but there is no nationally mandatory daily classification system for individual healthcare carers. So use the words that your organisation and your record system actually use. [22]
A reserved procedure may only be carried out by someone who is independently authorised to do so, or on the instruction of such a person. As an individual healthcare carer, you carry out such a procedure within an instruction, with local authorisation, a protocol and your own competence. Those are four separate conditions. Hysio does not infer any of them from your professional title. If you do not mention the person giving the instruction, the protocol or the sign-off out loud, they do not appear in the report either; what you do mention explicitly stays as a source fact. [24]
Authorised means that you are allowed to carry out the procedure, usually on instruction and within your organisation's framework. Competent means that you can actually carry it out at that moment. Both must be true; one does not replace the other. If at any moment you are not competent, you do not carry out the procedure, not even with a valid instruction. In your report you only record what you actually did and who gave the instruction, without adding a claim of authority. [13] [15] [24]
If your organisation works with Omaha, the classification sits in the record system, not in your spoken report. Hysio does not assign a problem code, intervention code or outcome score and does not convert any value. A code, score or cut-off value only appears when you name it yourself. So you dictate in plain words what the client reported, what you saw, what you did and what was agreed; linking this to a classification is done by you or your system, with your review. [13]
What the client said and wanted themselves stays separate from what you took over or supported. Because those two stay separate, you can read back what the client still did themselves and where the help began. The response shows how it turned out, for example that someone took up washing their upper body themselves again. Hysio does not draw a conclusion about an increase or decrease in self-reliance from this; you make that judgement, and only when you state it does it appear in the text. [3]
The Clinical & Behavioural Observation is intended for situations where the observation itself is the reason: a change in skin, breathing, eating and drinking, posture or behaviour that you want to record in a focused way. The Care Encounter Report is intended for situations where the care provided is the reason and the observation is part of it. The difference lies in the emphasis, not in a higher authority. Both formats are designed to record what happened; neither determines how serious something is. [4]
An observation comes back in the Shift Handover in the place where it belongs. The observation itself goes under the current care, the measurement under the care provided and measurement facts, and what your colleague needs to do with it under the points of attention for the next shift. So the handover does not repeat a full observation report, but gives the current state of affairs and the follow-up. If something has not yet been looked into, it remains an open action with the name of who picks it up. [5]
You dictate the care moment afterwards in your own order; the report converts that into fixed sections. Within each section, the timeline stays as you told it: first what was reported, then the observation, then the action, then the response. A time you mention stays with the fact it belongs to. Hysio does not move any event to another moment and does not fill in a time that you did not state. [3]
Go back to your own recording or note and find the passage that is not right. Adjust the text before you save it; if it is already in the record, follow your organisation's correction procedure, because a record entry does not simply disappear. Then check whether the change also affects the observation, the agreement or the handover to the next shift. Hysio never adopts a professional correction on its own; you decide the final text. [9]
Mark what is missing or unintelligible and leave it as an open point. Ask the colleague who was there a specific question. For a clinical or behavioural observation, do not fill in a word, value or decision because it seems logical. With voice-driven reporting, the rule is: half a measured value is not a measured value. If you are not able to make a passage complete, note what you do know for certain; then you decide whether the report can go into the record as it is. [9]
The Wet langdurige zorg (Long-term Care Act) funds residential care in the nursing home through a care profile, formerly the care intensity package (zorgzwaartepakket). Someone with a Wlz assessment who continues to live at home can receive care through a modular package at home or a full package at home. For your report, the funding does not change the content: you describe the same care moment. What does differ is the context in which your colleague reads it back, so state the place of the care moment when it matters in your situation. [17] [21]
Nursing and care at home fall under the Zorgverzekeringswet (Health Insurance Act), in the community nursing component. Funding runs through services set by the Dutch Healthcare Authority, with rates and rules that are revised every year. Those rules affect your organisation's recording, not the care content of your reporting. So keep describing what you saw, did and agreed with the client, and keep time recording for the organisation separate from the care report in the client record. [25] [22]
In residential care under the Wet langdurige zorg, care intensity is expressed in a care profile, formerly a care intensity package. Examples are VV04, sheltered living with intensive support and extensive care, and VV05, protected living with intensive dementia care. The profile says something about the client's assessment, not about what you did during one care moment. So do not adopt a profile code as an explanation for an observation; describe the observation itself and leave the assessment where it belongs. [23] [25]
For community nursing, the Dutch Healthcare Authority ran an experiment with client profiles alongside the regular services. As of 2026, those client profiles are no longer part of that experiment following a parliamentary decision, while the experiment with integrated services continues. For you, this is mainly organisational news: the form of funding does not determine what belongs in the client record in terms of care content. Keep describing what was observed, carried out and agreed, and leave the translation into a service to your organisation's administration. [22]
Traceable means that an outsider can follow your report without additional explanation. Specifically: every statement shows who made it, every measurement shows the value with unit and time, every action shows who carried it out, and every agreement shows who picks up what. Since January 2026, care at home, in the neighbourhood and in the nursing home has been assessed against one framework of standards. A report that separates these four things shows how the standards have been met. [17]
The Generiek kompas works with five indicators: three mandatory basic safety indicators and two that the organisation chooses itself. The mandatory three are advance care planning, medication incidents and attention to eating and drinking. The organisation must be able to show the Zorginstituut (National Health Care Institute) that the team has discussed these. Your reporting provides the material for this: a reported incident, a discussed wish around eating and drinking and the agreement made each belong in the record with date and those involved. [18]
An employer or client organisation can set registration in the Kwaliteitsregister V&V as a condition, for example for temporary staffing or as a job requirement, even though the register itself is not a legal obligation. It demonstrates continuing professional development and says nothing about the instruction, the authority or the competence for a specific procedure. Those three continue to apply per procedure. So do not confuse the register with a BIG registration, because the individual healthcare carer, as an article 34 profession, does not have one. [14]
A measured value goes into the report with the value, the unit, the side, the method, the time and the device used, insofar as you mention them. Hysio does not convert anything, does not fill in a missing unit and does not compare a value against a cut-off value. What you do not state is not added. If you say that the measurement was repeated or corrected, that stays as a separate fact next to the first value. [4]
First measure how things go now: how many minutes documenting, reading through and adjusting take together for an ordinary care moment. Then compare comparable care moments, not your busiest day with your quietest. Count the adjusting too, because a quickly made report that you then rewrite completely gains nothing. With AI reporting too, a gain is only a gain if the quality stays the same or improves. [9]
Start small: one documentation format, one type of care moment and a fixed group of colleagues. Agree in advance who checks the text before anything goes into the record, and who watches source, privacy and consent. Put a handful of practice situations alongside your usual way of working and discuss the outcome in the team. Only expand voice-driven reporting once the pattern holds over several weeks. [9] [8]
Hysio creates the report. You remain responsible for what you save in the record.