What does the aged care record-keeping requirement ask for?
Records about the individual must be accurate, current and accessible, with confidential information managed in line with the consent the person has given. The provider must be able to show the care and services delivered, the decisions taken with the person, and who delivered what, when an assessor or the person asks.
Answered from the held text of Aged Care Quality Standards ACQS25-2.12. The clause behind it is cited below, and the requirement page carries the evidence an assessor asks for.
What the clause behind this answer says
ACQS25-2.12 Accurate, current and accessible records about the individual
Information recorded about a person is accurate and current, and the person plus everyone in their care circle (their supporters, the registered health practitioners, the aged care workers, the allied health professionals and assistants, and others involved) can reach and understand it.
Source: Aged Care Quality Standards on the compliance desk. Our statement of the clause, not the instrument verbatim.
ACQS25-2.13 Confidential information managed in line with consent
Information about each person is kept confidential and handled appropriately, following the informed consent they have given.
Source: Aged Care Quality Standards on the compliance desk. Our statement of the clause, not the instrument verbatim.
What evidence answers it
- Records management procedure
- Audits of record accuracy and currency
- Access arrangements for individuals, supporters and practitioners
What assessors commonly find
- Records out of date or contradictory across systems
- Practitioners cannot access current information
The reviewer opens with
Show me records management procedure, and tell me who owns it and when it was last reviewed.
Read your own text against these clauses
Paste your policy or evidence pack and the reading marks, line by line, whether a phrase from each requirement appears and quotes your own words when it does. Read your pack, free