POLICY

Upraise Australia Care has processes in place to enable staff to maintain appropriate client records.

 

PROCEDURE

• Upraise Australia Care is responsible for creating a setting that supports quality professional documentation by:

1. Maintaining a documentation system that promotes pertinent sharing of information among team members while protecting client confidentiality.
2. Providing an appropriate physical environment, reliable equipment, ample storage, and quick retrieval processes.
3. Developing documentation policies, procedures, and forms.Employees are responsible for ensuring that `quality professional documentation’ is maintained on the client records.

• Documentation must be personalised to reflect the client’s needs, values and rights, and their involvement in service/care decisions.
• Recording clients’ comments supports understanding of their needs.
• Documentation must give a true and clear picture of the client’s perspective of their health and wellbeing, the plan of service/care, the service/care provided and, the effects of that service/care.
• Documentation must include all relevant information.
• Documentation must record all events as soon as possible, to reflect the client’s current status.
• A chronological entry, that is information recorded during or immediately after an event, reduces the likelihood of errors or misunderstandings and is more reliable than information recorded later which is based on memory.
• Record and sign a late entry after previous entries - remember to include the date and time of the event and the date and time it was written.
• Documentation must be written in plain language and, if abbreviations or symbols are used, must be well understood and approved by Upraise Australia Care.
• Remember to use the full word if the meaning could be misinterpreted.
• Correct spelling and punctuation aid understanding. Documentation must be based on clear and unbiased statements.
• Avoid unfounded conclusions or value judgments and meaningless or vague phrases.
• Disparaging remarks which criticise clients can bias other staff’s perception of the client.
• Documentation must be easy to read and decipherable.
• Documentation must be in ballpoint pen.
• Entries must be dated in full and authenticated by the signature and designation of the writer.
• The use of symbols and abbreviations should be avoided.
• The use of liquid paper (whiteout is discouraged).

Follow the required formats (forms):

 

Structure and Storage

Effective and consistent filing systems enhance client care/service by ensuring required information can be readily accessed by authorised personnel.

Storage of Client Record

Paper Client Records are filed in a secure location.

Security

Unauthorised persons are not allowed access to client record storage areas.

Electronic Health Records

Client records are maintained in the electronic system called Client Management System (CMS): iPlanit

Access to Electronic Record

Access to Client Management System (CMS): iPlanit is only available via passwords. Service manager are provided with a unique password which provides them with access to client records held in the system.

Electronic Back Up Procedure

Client Management System (CMS is backed up every week and process)

 

REFERENCES

Privacy and Personal Information Protection ACT 1998 (VIC) - promotes the responsible and transparent handling of personal information and balances the free flow of information with the protection of personal information.
Health Records and Information Privacy Act 2002 (VIC) – protects the health information of an individual
The Privacy Act 1988 (Commonwealth) – Covers the handling of personal information
Privacy Amendment (Enhancing Privacy Protection) Act 2012