Resources

Pressure injury documentation in Australian residential aged care follows a familiar pattern. The skin integrity assessment is completed and entered. The wound management form is initiated. The repositioning schedule is added as a care plan action. All three entries exist. All three are thorough. Under routine clinical governance, that is usually where the conversation stops.  It stops in...

Every residential aged care provider with active restraints maintains a restraint register. Most also conduct scheduled reviews and document them in progress notes. What most providers do not have is a record that can confirm, without cross-referencing three separate sources, that the review occurred at the documented time, that the consent in place at that moment...

 The shift had been busy. The afternoon Registered Nurse completed the handover at 22:00, briefed the incoming night team verbally, and filled in the handover sheet. One resident had shown increased confusion during the afternoon, which the outgoing nurse communicated during the briefing. The night shift came on. The handover sheet was filed.  At 02:30, the resident...

There is a version of this scenario in almost every residential aged care facility. A medication incident occurs. It is documented. The MAR shows the administration. The progress note exists. And when the question arrives, whether it’s from a Commission reviewer, from a SIRS investigation, from a board risk conversation, the record cannot answer it....

A quality report was submitted on time. The figures came from the clinical management system. The board received them, approved them, and they went to government within the statutory timeframe.  Fourteen weeks later, an ACQSC surveyor asked one question: where is the source record for this figure?  The provider could not answer. Not because the data was wrong....

You have signed the care minutes attestation. Your registered nurse hours met the benchmark for the reporting period. The reconciliation was completed, reviewed, and filed before submission. Everyone involved in the sign-off was satisfied with the figure. There is no reason to question it now.  The ACQSC compliance verification framework does not begin where you...