Managing and Tracking Documentation in an Aged Care Environment

However, this glut of documentation can be difficult to easily manage and navigate. How long does it take you to find files, track certain incidents across multiple care recipients, or check how many people in your facility have had a vaccination? What about if that file is five years old?

2020’s audits by the Australian Aged Care Quality and Safety Commission found that the third most failed standards requirement by residential Aged Care sites (after personal and clinical care) was Effective Governance Systems. Introducing better document management can help with this significant requirement for quality care.

To navigate a huge amount of documentation quickly and with modern search tactics, you need an enterprise file management solution that is up to the task.

Record keeping and documentation for Aged Care providers - difficulties faced

Extensive records across care recipients, staff, volunteers, and vaccinations - and more

No matter whether you run a residential center or meals on wheels service, you’re private or public, whether you’re part of a larger group or a sole operator, as an Aged Care provider, you will have records upon records upon records.

Aged Care providers are required by law to keep extensive and up-to-date records on care recipients, staff, volunteers, and vaccinations. This is not even to mention other record-keeping.

In Australia, this includes facility certificates, advice on aids and equipment, care plans and management, progress notes, performance monitoring, patient transport, support services for carers, visitor registration, and grounds maintenance. For a full list, take a look at the Record Retention Guide for organisations funded under the Service Agreement (2019).

Healthcare industry records

Aged Care providers can often be classified as healthcare organizations, too, or at the least provide some healthcare services, which is important for record keeping regulations.

In Australia, providers are required to keep records on patient care recipients who received a health service for no less than seven years, and up to even 25 years. In the US, it’s a recommended five years for patient file document retention. This can be difficult when records are across different systems (i.e. paper-based as well as digital).

Data security requirements

Data security in patient information must be guaranteed by law. In the US, healthcare facilities and providers and specifically nursing homes much comply with nationwide HIPAA patient privacy policy alongside local laws. Australian healthcare providers, and by extension Aged Care providers, are bound by a number of laws and legislations including the Privacy Act 1988, and various state and territory privacy laws. When you store patient information, it needs to follow specific rules.

Different authorities to report to for record-keeping

Most providers will need to keep different types of records for a number of different regulatory bodies. Knowing the right records to keep for the right auditing can be confusing.

May still rely on paper-based systems

Better funded and more modern Aged Care providers will likely have digitized all their systems. However, those who are a bit behind the times, or simply don’t know how to convert paper-based records to reliable, secure digital copies, will still rely - at least somewhat - on paper files.

Check-in, check-out filing system

With paper-based filing systems, this means that only one person can access files at a time. For legacy electronic medical records, you may not be able to have multiple users accessing and editing the same file at the one time.

The solution to managing and tracking documentation

An enterprise file management solution is the answer to the documentation difficulties faced in Aged Care. With the right solution, you’ll save a significant amount of time, storage space, training, and navigation complexity. 

You’ll be able to: 

• Surface files quickly
• Access the same file simultaneously from different users
• Search more efficiently across all records
• Organize files to a more granular degree using metadata
• Reduce paper-based storage overheads
• Reply to compliance requests quickly
• Improve information security

But choosing the right solution requires taking a serious look at both your needs, as well as the capabilities of current technologies.

CentricMinds enterprise file management has been designed with Aged Care providers in mind. We’ve consulted within the industry to uncover the most wanted features in a solution. 

Here’s what CentricMinds offers - and what you should look for in a document management system.

‍Native enterprise file management solution

Make sure that your files are kept secure, with zero-touch from outside software or locations. A native enterprise document management solution like CentricMinds is deployed in your own cloud and does not share data outside of this zone. This means all the management and organization is done only within your cloud space.

This helps with privacy compliance, as well as ensuring data is not exposed to outsider attacks.

Search file content, not just filenames

If Google only returned results that had the search words in the link, we wouldn’t be able to find what we wanted very easily. The same goes with enterprise search functionality. 

Say, for instance, we wanted to find a care recipient that really enjoyed the floral arrangement class performed by a particular volunteer. We could search for the volunteer’s name, and/or floral arrangement, and hopefully the care recipient’s name would pop up, with a note on their file saying how much they enjoyed the class. You need to be able to search within files to get this greater depth of information discovery that’s essential in a modern Aged Care environment.

Our enterprise search capability, CentricMinds Search, will search inside the content of Office and PDF documents and highlight keywords and phrases for the user. This way, you’ll be able to find what you need quickly.

Document Lifecycle: Retention, Archiving and Deletion

Within the aged care sector the tracking and management of documentation such as resident care plans, medication records, and incident reports is fundamental to operational performance. CentricMinds provides an effective way to keep track of documents across their entire lifecycle. Document authors can create content lifecycle guidelines that are unique to their organization.

With CentricMinds you can choose which documents to keep, archive, or delete based on criteria that you define.

For instance, you can decide which documents to keep based on the folders or subfolders they are contained within. You can also choose to keep files based on custom keywords, document type, metadata, and more. CentricMinds makes it easy to manage your documents by giving you the power to choose what happens to them.

You can decide to keep documents based on their location in specific folders, or based on the tags and metadata you’ve applied to them. You can also set time rules for retention, such as keeping files for one year after the last time they were accessed by a user.

Once you save your Content Lifecycle Guideline in CentricMinds, it will search through all files within CentricMinds Drive and automatically archive, keep, or delete content that matches the rules that you’ve set. This helps you stay organized and ensures that important documents are kept safe and secure.

CentricMinds provides a safety net to recover accidentally deleted files. You can even set retention periods for deleted content, giving you the opportunity to restore files before they are permanently deleted.

CentricMinds makes it easier to manage your aged care documents. You can easily keep important files, delete obsolete or unnecessary documents, and recover deleted files. You can relax knowing that your files are safe and easy to manage.

Regulatory compliance file management

You want your file systems to be automatically compliant with existing healthcare rules and regulations for data storage. File management for healthcare and Aged Care providers requires heightened security and configuration to stay within the law. 

CentricMinds supports regulatory compliance by conforming to an AWS HIPAA-approved cloud stack. The platform must be run in standard or high availability mode to remain compliant.

Other security features include multi-factor authentication, a granular security model, and session timeouts. If you choose for us to manage your CentricMinds infrastructure, we can take care of security audits, penetration testing, and antivirus.

Metadata tagging

To be able to sort and categorize documents more efficiently, CentricMinds uses a metadata tagging system that allows for detailed, heirarchical taxonomy. This way, files can be organized, surfaced, and categorized quickly, easily, and by anyone within your organization. Add tags such as care recipient’s primary caregiver, facility, level of care needed, and more. 

6  Reasons Why Documentation in Aged Care Is Important

It’s well known that documentation is a key part of giving personal and clinical care to people in aged care. Anything that could affect the quality of care for residents or just make them feel uncomfortable needs to be documented so that it can be properly evaluated and taken care of.

Yet, despite the importance of documentation and sharing that knowledge. In such a fast-paced and dynamic environment, it can be hard to keep it up and share it efficiently with staff. 

Now it’s more important than ever in aged care to demonstrate what is happening daily so that providers can meet the Eight Aged Care Quality Standards and comply with a quality review conducted every three years.

Some procedures and policies must be kept up to date. Writing and reporting are only two aspects of the job.

Communication is equally important. This means making it easy for staff to find documents and use them as part of their training. And also, sharing that information through announcements, news, and digital messaging engages staff.

Many aged care providers recognise the importance of documentation. However, many fail to realise the true value of this humble task.

Here are the top reasons for good documenting

1. Meet Compliance
   To avoid receiving a non-compliance notice or worse, sanctions from the Aged Care Quality and Safety Commission. Good documentation helps ensure that you conform to and meet the set standards.
   
   When unexpected events occur, such as a serious incident, complaint, or audit. Documentation is one of the most important ways to prove that everything is in order and compliant.

2. Communication
   Keeping good documentation and sharing important information with multidisciplinary team members benefits everyone. It helps the aged care provider coordinate residents' personal and clinical care. It also shows that the aged care provider supports its staff to get the right knowledge and training to do their jobs.
   
   
3. Assessment and Planning
   Documentation plays a key role in assessments and planning. When residents first enter an aged care facility, they're assessed to determine their needs, goals and preferences. These assessments are then used to plan for future care, even end-of-life planning.
   
   The results of these assessments are shared with the resident and documented in a care and services plan. This documented plan is shared with managers, staff, and other providers of care and services involved in the resident's well-being. Progress notes often form part of this documentation and identify health improvements or worsening health and well-being. Timely and appropriate referrals to individuals or other organisations and providers are initiated using this documentation.
   
   
4. Continuity of Care
   Documentation that is clear, accurate, relevant, and confidential supports continuity of care and improves communication between different healthcare professionals and the resident.
   
   Medical documentation for patients should be accurate, useful, clear, permanent, confidential, and dependable. Good documentation ensures that staff are aware of the clinical and personal needs of residents. It also helps staff and outside healthcare services to understand, track, follow up, and make informed decisions.
   
   In a fluid environment, external agency staff are frequently used on short notice. Documentation and clinical handovers enable actions to be taken to provide appropriate and safe resident care. 

5. Knowledge Transfer
   As part of an aged care team, everyone is responsible for the care and well-being of your residents. You are also responsible for keeping them safe, happy, and healthy.
   
   To do this well, you need to have access to shared knowledge that is relevant to your work. This might include training or professional development materials or documentation. Documentation can aid in knowledge sharing if it is well-organized, easy to find, and accessible.
   
   Outside providers are frequently called upon to provide clinical services in aged care. Shared documentation and knowledge have a positive impact and accomplish the following:

• It eliminates the need for the resident and family member to repeat their story repeatedly.
• Improves good decision-making and decreases unnecessary treatment.
• And it encourages the effective transfer of professional responsibility and accountability for care

6. Funding
   To be eligible for an Australian Government funding subsidy under the Aged Care Act. Aged care providers must be approved. Several criteria must be met to be eligible, and documentation is an important part of this.
   
   You must meet the requirements in Part 7A of the Commission Act as well as the Eight Aged Care Quality Standards.
   
   Progress Notes and Care Plans form part of the legal documentation that aged care providers need to successfully get funding. Progress notes detail the resident's care and any significant changes in their health. On a daily basis, they enable caregivers to communicate about the client's condition. Funding subsidies cannot be obtained without this type of documentation.

Types of Documentation in Aged Care

Documentation is one of the most important parts of working in aged care. It's a way to make sure you follow best practices and give the best care you can to your residents.

Documentation can include:

• Serious Incident Reporting
• Resident History and Progress Notes
• Care Plans
• Hand over notes
• Infection control
• Resident Records
• Observation Notes
• Correspondence
• Medical Records test results, x-rays, clinical photos, medication charts,
• Transfer forms
• Clinical summaries 
• And Policies and Procedures