Aged care providers are subject to an array of mandatory record keeping obligations under the Aged Care Act 1997 (Cth). But even if you put these legal obligations aside, there are still plenty of benefits to good record keeping.

The importance of having complete and accurate records was a salient issue in the Royal Commission into Aged Care Quality and Safety's Interim Report (Interim Report), which noted that poor record keeping can adversely affect consumer safety and the quality of consumer care.

Given the volume and types of data that providers handle daily, diligent record keeping can seem daunting and complex. But here are four reasons why good record keeping is essential:

1. Demonstrating Compliance

Providers have numerous legal obligations that don’t explicitly require record keeping. Having complete and accurate records is nonetheless valuable and crucial to demonstrating that your organisation is compliant. For example, demonstrating that a consumer has received safe and effective personal and clinical care, as required by Standard 3 of the Aged Care Quality Standards, requires complete and accurate records of the care and services delivered.

This seems obvious, yet poor record keeping was a recurring issue in hearings conducted by the Royal Commission. In many of the reported case studies, the Royal Commission was unable to make a finding of compliance with the expected standard of care because the records told a different story. No records meant no evidence to prove that the providers had given consumers the care they needed and were entitled to expect.

2. Delivering Safe and Quality Care that is Integrated and Holistic

Safe and quality care requires a multidisciplinary and collaborative approach that is integrated and holistic. This is repeated as a requirement throughout the Aged Care Quality Standards and requires a range of health professionals, advocates, external service providers, the consumer themselves, and their representatives and family members, to be involved in planning the consumer’s care. This ensures that the consumer’s clinical, health and wellbeing needs and preferences are being considered.

With so many people involved, care planning often becomes reliant on record keeping. Gaps or errors in documentation result in miscommunication, which compromises the delivery of safe and quality care. This crucial point is encapsulated in this statement by the Royal Commission, made during a hearing in Darwin (on 10 July 2019):

“Good care depends on good communication between the people responsible for delivering that care. Poor record keeping compromises the communication between those people.”

Providers can achieve effective communication by ensuring that each person who plays a role in the consumer’s care, including the consumer, has consistent, reliable, and up-to-date information available to them.

3. Monitoring, Accountability and Transparency

In the Royal Commission’s recent Accountabilities of Governing Bodies in Aged Care webinar (held on 4 November 2019), the speakers elaborated on the requirements of Standard 8 of the Aged Care Quality Standards, noting that good governance requires accountability and responsibility for each consumer and staff member within the organisation. Organisations need to implement systems that are designed to engage consumers, monitor consumer care and outcomes, and allow governing bodies to make proper and considered decisions about quality improvements.

Each organisation’s approach to this will differ, but at the heart of any approach is good record keeping practices. Effective monitoring, which promotes accountability and provides transparency, stems from complete and accurate records. Each person becomes responsible for the care and services that they deliver, and leadership and governing bodies become responsible for identifying gaps and errors, and therefore opportunities for improvements.

4. Prevention of Harm

Accurate and reliable records protect the safety of consumers and workers by facilitating the implementation of the correct risk and hazard control measures. Aged care providers generally face the same types of risks. But the level of risk, determined by the likelihood of a risk occurring and the potential consequences, can differ greatly.

Good record keeping saves organisations time and money. Using recorded data, rather than assumptions, increases the accuracy of risk assessments. It allows governing bodies to make better decisions about implementing control measures and empowers them to direct resources more efficiently. Good harm-prevention strategies equate to fewer accidents and injuries, fewer financial burdens associated with these incidents, and better consumer safety and care.

Three Steps to Establishing Good Record Keeping Practices

This guide to implementing an effective record keeping system is adapted from the Department of Health’s administrative record keeping guidelines for health professionals.

1. Have a Record Keeping Policy

A documented record keeping policy that is accessible and known to staff is the foundation of good record keeping. An effective policy:

• sets out clear standards expected at your organisation
• provides procedures that achieve consistent record keeping practices
• ensures that staff understand the purpose and principles behind the policy
• establishes clear roles and responsibilities with respect to record keeping.

2. Ensure Staff Know and Comply with this Policy

To ensure your staff comply with your record keeping policies and procedures you need to do two things. First, you need to ensure that they get sufficient training on the policies and procedures. Second, you need to make compliance a part of your organisational culture. This requires providing adequate support to staff to meet their record keeping obligations, which can include:

• providing appropriate record keeping tools
• informing all staff that record keeping is priority, as part of their record keeping training
• leading by example
• ensuring breaches of the record keeping policy are seriously investigated and have consequences.

3. Monitor and Report

Staff compliance was another key issue to emerge from the Interim Report. Multiple case studies contained examples of where organisations had policies and procedures in place, but staff did not comply with them. In addition, management had not identified breaches of the policies and, as a result, no corrective action was taken.

The management team and governing body should conduct regular audits of record keeping systems and associated staff practices. This allows for timely identification and analysis of gaps and issues, and appropriate corrective action. Remember, this is not a one-time task. Monitoring and reporting forms part of an ongoing cycle aimed at continuous improvement.

Final Thoughts

The hardest part of record keeping is establishing the system. But, once you have established an effective system that is dynamic and responsive to changes, you will be able to collect and use data to identify gaps and issues and take corrective action. In the long run, ongoing compliance will become much easier.

Good record keeping is a win-win for everyone. It facilitates consumer safety and quality care and helps you demonstrate that you have done the right thing. It also reduces organisational costs by minimising and controlling risks and optimising the use of resources.