How to Capture Emotional Wellbeing and Mental Health in Care Records
Share
🧠 Blog 6 of 7 in our Person-Centred Recording series for social care providers
This blog explores how to evidence emotional wellbeing and mental health needs in a way that is respectful, accurate, and person-centred — across care plans and daily records.
🧠 Emotional wellbeing is central to quality of life — yet it's often under-recorded in care documentation. Many daily notes focus on tasks completed or physical health, leaving out critical insights into mood, anxiety, mental health changes, or how people are feeling. For truly person-centred support, we must reflect the emotional as well as the practical.
❤️ Why Emotional Wellbeing Matters in Records
When we understand and support someone’s mental and emotional health, we improve:
- 🔄 Continuity of care — staff can recognise patterns or triggers
- 🧩 Personalisation — adjusting support based on mood or stressors
- 📈 Outcomes — improved engagement, behaviour, and quality of life
- 📣 Advocacy — making sure people are heard when they can't express it themselves
📝 What to Include in the Care Plan
Care plans should go beyond diagnoses to reflect the person's experience. This can include:
- What good emotional wellbeing looks like for that person
- How they express distress or anxiety — verbally or behaviourally
- What helps to soothe, reassure or support them
- Early warning signs and what actions staff should take
Include strategies based on individual needs, not generic statements — and update these regularly through reviews or observations.
📅 Recording in Daily Notes: Examples That Matter
Emotional support is often delivered in quiet, subtle ways. But that doesn’t mean it should go unrecorded. Here are some examples:
- “X appeared withdrawn today — engaged more after quiet activity offered.”
- “Spoke about missing family — staff offered video call which improved mood.”
- “Became anxious in busy room — supported to move to quiet space with sensory lights.”
These entries reflect emotional awareness, responsive action, and respectful support.
📁 Evidencing in Tenders and Inspections
Commissioners and CQC inspectors expect providers to recognise the importance of mental health, not just physical needs. In tenders, highlight:
- Staff training in mental health awareness and trauma-informed care
- Processes for monitoring mood or emotional changes over time
- How care plans reflect the emotional aspect of person-centred support
- Partnerships with mental health professionals or support services
📚 Explore the Full Person-Centred Recording Blog Series:
- 1. What Does ‘Person-Centred’ Really Mean in Daily Practice?
- 2. How to Record Person-Centred Approaches in Daily Notes
- 3. How to Evidence Choice and Control in Social Care Records
- 4. How to Record Meaningful Goals in Person-Centred Care Plans
- 5. How to Evidence Communication Needs in Care Records
- 6. How to Capture Emotional Wellbeing and Mental Health in Care Records
- 7. How to Evidence Person-Centred Support in Shared Living Environments