Documentation in Aged Care

As providers of aged care you know that comprehensive, contemporaneous, and accurate documentation is the fundamental key which enables you to evidence the quality care that you provide and to demonstrate compliance with your obligations under the Aged Care Act 1997 (Cth).

Following the announcement of the Terms of Reference, and as expected the Commission has a wide scope of inquiry. The Commissions’ scope of inquiry includes care recipients, aged care workers and ‘any matter reasonably incidental’ to a matter referred to within paragraphs (a) to (f) of the Terms of Reference.

Document Retention, Records Management and Destruction Practices 

Records are permitted to be kept and retained in written or electronic form under the Aged Care Act 1997 (Cth).

Under the Australian Privacy Principles and state based laws relating to health records, the records approved providers hold regarding care recipients may only be deleted or destroyed in accordance with Health Principle 4, that is, seven years after the last occasion a health service was provided to the individual.

Additionally, providers of aged care also retain Human Resources records and records related to funding arrangements, and other financial matters.

Aged Care records can be voluminous and may include a significant level of clinical detail. The Royal Commission will require records to be provided in a timely manner.

• Do your current document management practices enable you to access all records easily and effectively?
• Do you store historic records off site in hard copy only?
• Are your records stored in a systematic manner which enables you to access them quickly?
• Do you have a centralised document management system or are your records managed at branch or site level?

We recommend that you review your current document retention, record management and document destruction processes, and conduct an assessment of your organisations risk including:

• whether your current procedures include converting all hard copy records into electronic formats;
• whether you have an effective document management system in place to store and access records;
• a review of your archiving processes, do they need to be amended or updated?;
• a consideration as to whether your organisation has a backlog of records which need to be archived?;
• identifying where data may be stored throughout your organisation (both electronic and hard copy records, at head office, at site, in drawers, filing cabinets and storage areas);
• developing a strategy on how your organisation will extract documents and information to enable you to provide records in a timely manner if required to do so;

We also recommend that any practices you currently have in place which permit hardcopy records which are more than seven years old to be destroyed be ceased.