The note is written before the shift ends.
Built for long-term care. Your team dictates at the bedside. CareTrace writes shift notes, incident reports, and service plans into your EHR.
What lands in your EHR.
One bedside dictation becomes a survey-ready note. Title 22 and regulation-aware, filed to PointClickCare, YardiOne, or Netsmart.
Staff speak. CareTrace writes what actually ends a shift: shift notes, incident reports, service plans. A licensed nurse signs before anything reaches the EHR.
See how a shift runs on CareTrace.
A real 7pm to 7am shift across assisted living, memory care, skilled nursing, and hospice. Seven moments where a nurse or caregiver actually documents. Each one filed as it happens.
See how a shift runs on CareTrace.
A real 7pm to 7am shift across assisted living, memory care, skilled nursing, and hospice. Seven moments where a nurse or caregiver 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 resident 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 RN's queue.
The RN 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 RN's review queue, and Maria is moving to the next room before the RN 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 a 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 check, neuro checks, notification chain. The RN edits the vitals and signs. In RCFE, the Title 22 §87211 seven-day report queues. In SNF, the 42 CFR §483.12(c) 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 RCD or DON opens the admin dashboard at handoff. Eleven drafts from the shift, eleven signed by a licensed nurse, zero unattested. The incident packet is already queued for the 8am review, with time of event and notification chain populated.
Trained for the chaos of the shift.
Interruptions, corrections, call bells, half-sentences. CareTrace pulls the signed Title 22 §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 Title 22 §87211 incident report
Incident report. Mrs. R., 02:34.
- Time of event
02:34, Room 214-B. Found by caregiver 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 RCD / DON
- Title 22 §87211 report queued
Due 2026-05-26 to licensing + responsible party.
- Service plan update
Bed alarm on · Morse score 65 · PT re-eval ordered · QAPI flagged.
The 24-hour binder, digital.
Five places to write the same observation, now one. Care Manager notes route to the assigned Nurse the moment they're written. By 10 AM the night is reviewed and signed.
Morning standup
Tue · 10:00
- Room 506 · G. Stewart 07:00
- Catheter 100mL clear. Refused breakfast, accepted Ensure.
- Room 511 · N. Reyes 21:42
- Refused 8pm meds. Pushed cup, said not tonight. Settled after 20 min.
- Room 520 · M. Alvarez 23:15
- Reddened area on sacrum during pericare. Did not blanch when pressed. No broken skin.
- Room 522 · J. Park 02:30
- Found on floor left of bed. Says she's okay. No visible injury. Called nurse.
Care Manager · routine
Med Tech captured · RN reviewed
Care Manager observed · RN started skin assessment
RN alert charting · LIC 624 drafted · family + MD call queued
- The paper 24-hour binder is replaced by a live screen, in room order. Illnesses, incidents, refusals, and out-of-building entries all read at once.
- Care Manager notes route to the assigned Nurse for review. The Care Director is cc'd or escalated based on triggers.
- Capture once, distribute many. One fall observation triggers alert charting, the LIC 624 draft, and the family and physician notifications it requires.
- Every entry is signed, timestamped, and exportable. The standup is the audit trail.
How we write into your EHR.
An extension fills out the form the reviewer would have typed.
The reviewer 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.
Integration at pilot is simple for that very reason. We don't ask PointClickCare, YardiOne, or Netsmart to open anything up for us. The note is ready, the reviewer signs it, and the extension files it into whatever 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.
Fifteen-minute walkthrough on your community's workflow. We bring the voice capture, the EHR fill, and the security packet. You bring the questions that actually matter.