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As the Aged Care sector becomes more regulated, conventions around recording and filing of client information and incident reports have become more important. Compulsory reporting means that all approved providers must keep consolidated records of all incidents, particularly those involving allegations or suspicions of reportable assaults as set out in the Residential Care Manual (p253). The documentation of these incidents demonstrates that an organisation has met the accountability requirements under the Aged Care Act 1997, Residential Care Manuals and other quality assurance standards. For a facility to be fully compliant these incidents and patient files need to be maintained and stored in purpose designed storage facilities for archiving paper and digital files.

An Aged Care organisation must also ensure that those in their care are aware that information recorded in their client file is confidential and only available to those who have an appropriate role to assist the person in this matter. The documentation of alleged incident reports and prevention strategies is an important aspect of any care plan and in cases involving alleged abuse it can also have legal ramifications.

The documentation in the client file needs to:

  • Be dated and signed

  • Contain well organised factual descriptions of what has been said and by whom or observed

  • Contain clear and concise history/background of the alleged abusive behaviour and whether the behaviour is intentional or unintentional

  • Information must be recorded in a professional and accurate manner, with behaviours described without emotion

  • Use verbatim statements that the older person or family/friends uses to describe the situation

  • Provide details of any meetings held, with whom and the issues discussed

  • Provide factual details of logical explanations, supporting details or documentation

  • Ensure that the recorded directives or actions to resolve the abuse are consistent with the identified issues

  • Ensure that any police reports are included for reportable incidents

Storing of information needs to uphold the older person's rights to confidentiality and access to information needs to be on a need to know basis. This information can be stored either physically on the aged care premises or off site at a secure archive facility. If the information is stored in a digital format then the aged care facility needs to ensure that all security protocols are strictly maintained.

Formfile is working with many aged care and not for profit centres to ensure that all their incident reports are recorded in the appropriate manner and are compiled and catalogued in such a way that the information is easily retrievable. Category 1 incident reports are isolated and individually recorded with the client name, date and time and kept on a permanent basis. Hard copy documents are stored in the Formfile Record Centre where they are barcoded and available online if required. All category 2 and 3 incidents are grouped and able to be destroyed 7 years after the incident; they can also be made readily available in a digital format as required.

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