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Effective record keeping is proven to have direct benefits to consumer health and wellbeing outcomes as well as to the efficient day-to-day operations of a care home. It contributes to clear communication, planned care, care evaluation as well as various reporting requirements. Having clear, complete and consistent records go a long way to ensuring that providers’ regulatory agency reviews happen seamlessly, with minimal amount of stress and interruption to daily activities.  

Effective documentation begins with an organisation’s policies and procedures. It is essential that policies set out clear expectations that consumer’s documentation is kept up-to-date, accurate, compliant with continuously evolving legislation and, is shared with relevant professionals inputting into the consumer’s care. The procedures must then outline the systematic approach to identifying and addressing risks for every consumer. Standardised and periodic file review is the only way to identify compliance with the organisational and legislative directive. Variability in file completeness indicates that either policies and procedures are not adequate to support staff in their roles, or instructional documentation is not being followed. This may be due to a variety of reasons including time constraints or the expertise base of staff.

Just as with audits, an impartial approach to the consumer file reviews is often beneficial to identify issues and potential continuous improvements. External independent reviews are often the required catalyst to make the enduring changes to identify and correct gaps in the consumers’ files. 

Anchor Excellence Assurance file review methodology ties together multiple facets of consumer documentation to ensure it aligns with set organisational policy and procedures, in addition to the Aged Care Standards and legislative requirements. An Anchor Excellence Assurance file review may be able to identify the needed improvements to address:

  • Deterioration or changes in diagnosis that require a referral and provision of services by a specialist
  • Missing or out of date assessments and subsequent updates to the care plan
  • Changes in consumer’s needs and high impact risks that may be evident through the analysis actual and near miss incidents such as falls and medication incidents;
  • Evaluation of care provided including medication administration effectiveness review
  • Adequacy of Incident Management systems, Serious Incident Response Scheme (SIRS) reporting, and timely notification appropriate government departments
  • Use and monitoring of restrictive practices
  • Compliance with open disclosure obligations
  • Ensuring restrictive practices are documented and are being monitored, for example checking than there is a specific diagnosis for the prescribed psychotropic medication, behaviour and site charts are in place
  • Progress notes acting as a measure of the consumer’s care needs of residents and historical detail for the provision for these needs
  • Clinical, care and support service team communication and understanding the consumer’s needs 

This list is by no means exhaustive but is only an example of issues that can be discovered. 

Ongoing efforts are being made by the aged care industry, providers and developers of various clinical systems to simplify documentation maintenance, however the output of those systems remains as good as the information entered into them. This is why a review of each consumers’ case file is crucial to the identification of improvements in each consumer’s file and where necessary the organisation’s policies and procedures.

For more information about Case File Reviews, please feel free to contact Anchor Excellence.

Dr Irene Stein

Head of Clinical Governanace

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