Nursing home software: every resident, every dose and every shift in one place
Nursing home software has a job clinic software was never built for: following people who live with you, around the clock, across three shifts and many pairs of hands. This guide covers what a resident's record must hold, one shift in OPALEVI, and what to ask before choosing.
Key takeaways
- A care home runs on shifts, not appointments: the program should show who sleeps where, how the last shift found each resident and what is left before handover.
- Every dose should leave a trace: given, refused, held or missed, with the time, who recorded it and, if you want one, a witness.
- Close each incident only with a written outcome; a serious one should reach the managers the same day.
- OPALEVI records what staff observe and the plan you agree; it gives no frailty or pressure-ulcer score, so the judgement stays clinical.
Why a care home outgrows paper charts and clinic software
Most homes begin with paper that works: a medication chart on a clipboard, a handover book, a notebook for falls. Then the home grows, staff change, and the gaps show:
- A dose nobody can account for. The box is empty: refused, held on the doctor's word, or forgotten when the bell rang?
- A handover that lives in one head. The night nurse knows who slept badly; by mid-morning that knowledge has gone home with her.
- A fall written in three places, or in none, and no trace of what was decided afterwards.
- Software made for appointments. Clinic programs expect patients to arrive and leave. Residents stay for years, and their day is measured in shifts.
In a care home, the record is the handover. If the next shift cannot read it, it might as well not exist.
What a resident's record has to hold
Whatever you use, paper included, each resident's record should answer these questions without a phone call:
| Field | Why it matters |
|---|---|
| Room, bed and type of stay | Who sleeps where tonight, and whether the stay is long-term, respite or short. |
| Family, emergency contact and guardian | Who to call first, who may consent for the resident, who may be told about their care. |
| Consents | What was agreed, in the words that were shown, and whether it still holds. |
| Observations for each shift | Sleep, eating, mood, skin and pain, so a slow change is noticed early. |
| Medicines and every dose | What was prescribed, and what happened at each round, and by whom. |
| Incidents and their outcome | What happened, what was done at once, what was decided later. |
| Care plan and geriatric review | Agreed needs and goals, falls, mobility and continence, and when the plan is reviewed. |
A record, not an inspection form
Inspection rules differ by country. Software keeps the facts: who, what, when, and who wrote it down. Ask your regulator which documents to keep.
Rooms, residents and families in OPALEVI
Registered as a nursing home, OPALEVI for nursing homes speaks a care home's language: people are residents, visits are care notes, and the menu holds Residents, Rooms, the Medication round and Incidents. Nursing care, Geriatrics and General practice are ticked for you at registration.
Rooms shows every bed with its resident, the admission date and the stay type, or that it is free. Admitting takes one sheet: a free bed, the resident, and Long stay, Respite stay or Acute stay. For residents who moved in before OPALEVI did, Admitted on (optional) keeps the real date.
Move to another bed keeps both stays on the record. At Discharge, the resident's running medication orders are listed, already ticked, so a doctor can stop them in the same step. Hospitals use the same board; see hospital surgery and ward software.
Residents groups everyone by room, with the days since admission, the Last observation, Open incidents and the Emergency contact, callable from a phone. Each file holds Family and contacts, up to twenty people, each of whom can be marked as the emergency contact, a Legal guardian or someone who May be told about care. Resident consents keeps the exact words signed; a consent is withdrawn with a reason, never edited.
One shift, step by step
A morning shift in OPALEVI, from signing in to handing over:
Start from Today
A nurse's Today opens with No observation this shift, the residents nobody has written about since the shift began, and Doses due now, most urgent first. Reviewers also see Incidents to review.
Record how each resident is
Daily observations takes a subject (sleep, nutrition, mood, skin, pain and five more), a rating from 1 to 5, a note, or both. The shift is preset from the clock (the three begin at 06:00, 14:00 and 22:00), and the writer can change it. Save observation updates the residents board.
Give the medicines
Open the Medication round and work room by room, as the next section shows.
Report what happened
A resident is found on the bathroom floor. Whoever finds her chooses Report an incident: time, place, kind (Fall), severity, what happened and what was done straight away. A major or critical incident also creates a task for the administrators, due that day.
Hand over
The round's Still to do view shows doses nobody recorded; the next shift sees them flagged as left from the earlier one.
Anyone may report an incident, and the description appears only on the incident's own page, never in notifications. Reviewers, the administrators by default, see every report, Take into review and Close with this outcome; no incident closes without one.
The medication round: every dose accounted for
The medication administration record matters most on an ordinary day, and paper handles it worst. In OPALEVI a doctor writes the order on the resident's file with New order: medicine, dose, route, up to eight times a day, start and end dates and instructions, or As needed for extra doses given with a reason. Orders are never edited: a change means stopping the order with a reason and writing a new one.
The Medication round shows one shift, room by room, with five counts on top. Its timing is a clock rule: a dose can be recorded from an hour before its time, is flagged late after 30 minutes and becomes Overdue after an hour. The nurse records Given, Refused, Held or Missed; refusing or holding needs a reason, and Time and witness keeps the real time and a colleague who saw it. A dose takes one outcome only: a second attempt shows who already recorded it.
On the file, Last 7 days lays the week out as a grid, so refusals stand out at a medication review. An order linked to a stock item takes one unit off it for each dose given.
A record, not a prescribing check
OPALEVI does not check doses, interactions or allergies, and late or overdue are clock rules, not clinical advice. Those checks stay with your doctors, nurses and pharmacist.
Wounds, falls and the care plan
Clinical notes live in two department records; a nurse can enter the vital signs before the clinician writes the rest.
The nursing care record holds the care setting and plan, the Mobility level (from independent to hoist or bed bound), personal care, food and fluid intake, and Wounds on the body: pins on a photographed figure, each with its state and its length and width in millimetres. The sacrum has its own zone on the back view.
The geriatric assessment asks about Falls in the last 12 months, the mobility aid, a Pain map with a 0–10 intensity, continence, cognition, Regular medicines, nutrition and Advance wishes. The clinician types both counts; they are not worked out from incidents or orders.
Both records end with Care plan and falls prevention: up to twenty lines of need, goal, action, who and review date, eleven standard falls-prevention statements to tick, and the next review. It prints for the family and carers, without the advance wishes. No Braden or Clinical Frailty Scale score is kept, and no plan line writes itself. For therapy after a fall, read physiotherapy clinic software; for mood or behaviour, mental health practice software.
Questions to ask before choosing nursing home software
Answer these during a trial with your own residents, not in a demonstration.
| What to ask | What good looks like | OPALEVI |
|---|---|---|
| Who lives in which bed, since when? | Rooms, beds and the type of each stay on one board. | Yes: Rooms and the residents board. |
| Does each shift know whom it has not seen? | Residents without an observation this shift. | Yes, on Today. |
| Is every dose recorded with its outcome? | Time, reason and, if wanted, a witness. | Yes: the medication round. |
| Are incidents closed with an outcome? | Anyone reports; a reviewer closes in writing. | Yes; serious ones become a task. |
| Does each role see only its own work? | Nurses give, doctors prescribe, finance sees no notes. | Yes, adjustable permission by permission. |
| Does it score frailty or pressure-ulcer risk? | Only with a licensed tool. | No: it records, it does not score. |
| Does it check prescriptions? | Interaction checks, or a clear no. | No. |
| Does it bill the monthly fee itself? | Recurring charges, or a quick invoice. | Partly: you invoice each resident; stays are not billed automatically. |
| Can families log in? | A portal, or at least a printed plan. | No portal; the care plan prints. |
For a broader checklist, read how to choose clinic software; the features page lists the rest.
Your first week with OPALEVI
Register and build the rooms
Register as a nursing home. Rooms are not created for you: add them under Manage rooms with Add room and Add bed.
Admit today's residents
Use Admitted on (optional) for the real dates, and add an emergency contact for each resident.
Move the charts
Doctors rewrite current medicines as orders, one floor at a time, beside the paper chart for a few days.
Invite the team
Invite your colleagues with their roles, so every dose carries a real name.
One floor, one week
Run one wing fully in OPALEVI for a week. By Friday you will know whether it fits your shifts.
Frequently asked questions
What is nursing home software?
A program that keeps a care home's records together: residents and their rooms, observations for each shift, medication orders and every dose, incidents, care plans, family contacts, consents and invoices. It replaces clipboards and handover books with one record every shift can read.
Can nurses use it on a tablet during the round?
Yes. OPALEVI opens in a web browser, on a computer, tablet or phone, without installing anything, though it needs an internet connection. On a phone or tablet the menu moves to a bar along the bottom, so a nurse can carry a tablet from room to room and record each dose at the bedside.
Can reception or the accounts team read clinical notes?
Finance never reads clinical records. Reception can admit residents to beds, report incidents and take payments; whether it may also read clinical history is a switch the home controls. By default nurses record observations and doses, and only doctors and administrators write medication orders.
Can OPALEVI bill a resident's monthly fee?
Partly. A stay is not charged by the day or the month on its own. You issue each resident's invoice from their file, with prices from your own list of services, record the payments, and follow what is still owed under Residents with outstanding balances.
Does it suit a home care service?
Yes, registered as home healthcare. Each appointment is marked at the clinic or at home, and the Home-visit route lists the day's visits with address, phone and a map link. A patient can be emailed a reminder the day before. There is no residents board, shift observations or medication round for home care. See OPALEVI for home health.
What does OPALEVI cost, and is there a trial?
You pay for each staff member who uses OPALEVI; residents, rooms and departments are never counted. Registering starts a free trial, no card. Without a plan at its end, nothing is charged and the records turn read-only. See the pricing page.
