Templates and Forms

Forms are frozen decisions: someone once decided what information matters at this moment — an incident, a visit, a supervision — and turned it into boxes. Good ones ask exactly what the next reader needs and gently force completeness (a body map you must mark, a time field you must fill). Bad ones invite "as usual, no concerns" until the day it wasn't usual and nobody can say why.

This page describes what strong versions of the everyday forms contain, and links to printable generic examples you can use for training, comparison or as a starting point for your own versions. They are deliberately unbranded and carry a reminder to follow local policy — your organisation's approved forms and digital systems always take precedence.

• Regulation 17: whatever the format, records must be accurate, complete, contemporaneous and secure.
• UK GDPR: forms should collect the minimum needed (data minimisation) and be stored/retained lawfully.
• Specific records are effectively mandated: MAR charts (safe medicines management under Reg 12), accident books (Social Security regulations), recruitment records (Reg 19 Schedule 3), and complaint records (Reg 16).
• See the Documentation topic for the writing standards that apply inside every box.

CQC cares about the information, not the stationery — but assessors notice when forms fight good practice: incident forms with no field for actions taken, supervision templates that are one line of "no issues", daily note formats that invite copy-paste. They also notice the opposite: body maps used at the first bruise, PRN records with effect columns completed, audits whose action columns have dates and initials. If your forms make those behaviours natural, the paperwork will evidence care instead of merely accompanying it.

• Daily visit / shift note: person, date, times in/out, care delivered against the plan, food and fluids (amounts), continence, skin observations, mood and activity, concerns, actions, author. Printable example.
• Incident / accident form: who, what, when, where, witnesses, injuries (with body map), immediate actions, notifications checklist (manager, family, GP, CQC, RIDDOR, safeguarding), follow-up actions and sign-off. Printable example.
• Body map: front/back outline, each mark numbered with description (size, colour, type), date first seen, linked incident or explanation, review dates. Printable example.
• Supervision record: wellbeing, workload, casework discussion, practice feedback both ways, training needs, safeguarding prompt, actions with owners and dates, both signatures. Printable example.
• MAR chart: use pharmacy-printed or system-generated charts wherever possible; handwritten entries double-signed; codes defined on the form itself.
• Audit templates: whatever the subject, the columns that matter are finding → action → owner → date → checked. An audit without a checked column is a wish list.

Example 1. A team's incident forms keep coming back with the notifications section blank — not because staff don't notify, but because the section was a wall of small print. The manager redesigns it as six yes/no tick lines with a "time notified" box each. Completion hits 100% in a month. Nobody became more conscientious; the form stopped hiding the job.

Example 2. During induction, a new starter practises on the example daily note template with a role-played visit, then compares it with the agency's real digital form. The differences spark exactly the right questions ("where do fluids go?", "how do I record a refusal?") before her first real shift — which is precisely what generic templates are for.