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Would your clinical notes stand up under scrutiny?

Would your clinical notes stand up under scrutiny?

The adage of "if it isn't documented it didn't happen" has evolved in the last two decades from when the phrase was thrown around liberally. 

In a work environment that demands accountability, and more documentation dependent workplace than ever before, and an increasingly litigious world, it isn't enough to write anything, we need to document accurately and in a detailed, timely way. And with the spotlight on Aged Care as we navigate COVID-19, never has this been more important.

Standard 3 (3c/ 3d/3e/3f)) discusses the nuances of aged care documentation. If you are documenting or allowing team members to document on your behalf, then this is a Standard you, and the person you delegate documentation to, need to be all over. 

The most common aspect of provider documentation failure at audit has historically been:

  • Inadequate documentation of End of Life wishes and preferences for consumers.
  • End of Life care plans not always consistently in place.
  • Failure around documenting the changes in a consumer's condition rather than the failure to recognise the changes including behavioural changes; mental health conditions; deterioration of wounds; skin conditions or identification of pressure injuries. 
  • Care plan documentation lacking detail to deliver appropriate care or understand the needs and preferences of consumers, especially if a change of condition had occurred or after an incident.
  • Medical Directives not reflected in Care Plans.
  • Discrepancies between electronic records and consumer paper files.
  • Consumers having to repeat their care needs and preferences to staff, especially if staff were rotating.
  • Staff reliant on assumed knowledge about consumers rather than care planning documentation.

If you recognise any deficiencies within your team's documentation, you could be placing your facility at risk. Create the simplest path to documentation and audit success by calling HCA Online Learning on 1300 952 433 or click here to download our full learning library.

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