The note is written before the shift ends.
Nurses dictate at the bedside. CareTrace writes assessments, incident reports, and care plans into your EHR.
What lands in your EHR.
One bedside dictation becomes a survey-ready note. Title 22 and F-tag aware, filed to PointClickCare, Yardi Senior Living, or Netsmart.
Nurses speak. CareTrace writes what actually ends a shift: assessments, incident reports, care plans. The nurse signs before anything reaches the EHR, so the license never leaves their hands.
See how a shift runs on CareTrace.
A real 7pm to 7am shift across skilled nursing, assisted living, memory care, and hospice. Seven moments where a nurse actually documents. Each one filed as it happens.
See how a shift runs on CareTrace.
A real 7pm to 7am shift across skilled nursing, assisted living, memory care, and hospice. Seven moments where a nurse actually documents. Each one filed as it happens.
- 19:00
Open the app, see tonight's assignment.
Maria pulls out her phone at the hallway cart. CareTrace opens to her patient list for the shift, preloaded with the residents she is covering. The mic is one tap from every row. In two-party consent states, the posted resident notice is confirmed on the lock screen before a microphone ever opens.
- 21:42
Speak once, two notes land in the LVN's queue.
The LVN attempts the med pass. The resident turns her head and pushes the cup. Maria watches from the doorway and speaks the observation once. CareTrace drafts both a med refusal note and a behavior note, routes them to the LVN's review queue, and Maria is moving to the next room before the LVN signs.
- 23:15
Dictate without Wi-Fi. The note still writes.
Toileting round, dead-zone hallway. Maria dictates the finding: non-blanchable redness at the sacrum, no open area. The draft holds locally on the phone, syncs when she passes the nurse's station, and lands on the RN's queue with an F686 skin-assessment flag already attached.
- 02:30
An unwitnessed fall, filed the way a surveyor reads it.
Maria dictates at the doorway, then kneels to check. CareTrace structures the incident the way a state surveyor reviews it: found position, last known status, injury assessment, neuro checks, notification chain. The RN edits the vitals and signs. In RCFE, the §87211 seven-day report queues. In SNF, the F689 packet queues.
- 03:14
Speak in SBAR. CareTrace structures it the way the MD reads it.
SpO2 drops, new confusion on the 3am round. The RN dictates naturally. CareTrace structures the note as Situation, Background, Assessment, Recommendation, the shape the MD will read. The RN edits, signs, logs the callback, and the note is in the EHR before the return call comes in.
- 06:30
ADLs captured room by room, no end-of-shift retype.
Continence care, ambulation, intake, skin check. Dictated in the room, the moment it happens. CareTrace batches the observations into the flow-sheet rows PointClickCare expects, filed as Maria moves. At 6:30 the grid is full. No end-of-shift catch-up. No column left blank at handoff.
- 07:00
Eleven drafts. Eleven signed. Zero unattested.
The DON opens the admin dashboard at handoff. Eleven drafts from the shift, eleven signed by a licensed clinician, zero unattested. The incident packet is already queued for the 8am review, with time of event and notification chain populated.
Trained to perform under chaos.
Interruptions, corrections, call bells, half-sentences. CareTrace pulls the signed §87211 out of the way it actually gets said.
Raw floor audio
Unwitnessed fall. Room 214-B.
- Two thirty four AM, room 214, no wait, 214-B. Mrs. R, she's on the floor.
- Right side, uh, eyes open, she's talking to me, she's fine, she's fine. Maria can you grab the gait belt, thanks.
- Unwitnessed, I was in 216, heard the thud. Bed was low, call light on the pillow, floor mat in place, so.
- Hey sweetie where does it hurt, okay hip, she says like a four, no head strike, no blood, nothing.
- (call bell) hold on, that's 210, Maria's got it. Um, paging Ruiz, daughter after the RN clears her, start the report.
Structured §87211 incident report
Incident report. Mrs. R., 02:34.
- Time of event
02:34, Room 214-B. Found by aide during rounds.
- Witness posture
Unwitnessed. Bed low. Call light on pillow. Floor mat in place.
- Injury assessment
Hip pain 4/10. No head strike. No visible injury. A&Ox3.
- Vitals
BP 128/74 · HR 82 · RR 18 · SpO2 97% · Temp 98.2°F · Pain 4/10
- Notification chain
02:41 MD paged · 02:52 returned · 03:05 RP · 07:15 DON
- §87211 report queued
Due 2026-04-27 to licensing + responsible party.
- Care plan update
Bed alarm on · Morse score 65 · PT re-eval ordered · QAPI flagged.
How we write into your EHR.
An extension fills out the form the reviewer would have typed.
The nurse dictates at the bedside. CareTrace drafts the note. The reviewer opens the admin dashboard and signs it. The extension, running in the reviewer's own browser, reads that signed note and types it into the EHR the same way the reviewer would have.
That's why a pilot doesn't need an IT project. We don't ask PointClickCare, Yardi Senior Living, or Netsmart to open anything up for us. The note is ready, the reviewer signs it, and the extension files it into whatever web-based EHR your building already uses.
How we handle security
HIPAA-aligned
Encryption in transit and at rest. Role-based access. Full audit trail.
BAA available on request
Signed before any PHI enters our systems.
PHI never used for training
Not our models, not any third party's.
U.S. data residency
All PHI stored and processed in U.S. regions.
Audit logs
Every access to a resident record is logged and exportable.
SOC 2 Type II in progress
Observation window underway; security packet on request.
See CareTrace on your floor.
Twenty-minute walkthrough on your facility's workflow. We bring the voice capture, the EHR fill, and the security packet. You bring the questions that actually matter.