AI documentation in residential aged care

Under the Aged Care Quality Standards care has to be based on ongoing assessment and planning, and the assessment behind each decision has to reach the facility record. A new admission needs a current problem list, the medicines the resident arrived on, and the goals of care with the name of whoever was consulted.

Consent to capture is asked at the first review and recorded in that review's entry. Capacity is decision-specific, so a resident living with dementia may be able to agree to a scribe and not to a treatment decision. Where the resident cannot consent, the request goes to the substitute decision-maker recognised under state or territory law: an enduring guardian, an attorney or the person responsible.

Staff and family in the room are captured too, so everyone present is told first. The record shows:

• who consented, the resident or a named substitute decision-maker
• the date given, and the date revisited after a change in capacity or decision-maker
• any refusal, and the entry written by hand for that review

The entry carries the assessment behind each finding, what has changed since the last review, and the date the plan is next reviewed. A bed rail put up after a fall is a mechanical restrictive practice, so the reason and the review date go in the same entry. A deteriorating resident needs the changed observations, what was excluded, and written instructions on when to transfer and when to treat in place, with an after-hours number.

Every start, cease or dose change needs a documented indication and a rationale. A psychotropic prescribed to influence behaviour is a restrictive practice under the aged care legislation, and the record has to show the assessment, the alternatives tried, the informed consent of the resident or their restrictive practices substitute decision-maker, and the review date.

A Residential Medication Management Review returns an accredited pharmacist's report, and the prescriber's response to each recommendation belongs in the record, adopted or declined.

Where the conference is claimed under an MBS multidisciplinary case conference item, the record-keeping requirements attached to that item apply, including the participants, what was agreed and who is doing what next.

The facility cannot act on a decision from the visit until the letter arrives and a staff member enters it into the care record. A letter goes to the usual general practitioner, one to the facility for anything nursing staff have to action, and a referral where the conference raised one.

A clinical governance lead settles two things first:

• how a signed note and a facility letter reach the care record, and who enters them
• where audio is held, how long it is kept, and how consent is evidenced when the substitute decision-maker is not present