Recording incidents helps you understand what happened and what to do next.
Under the Serious Incident Response Scheme (SIRS), you must record incidents that happen. This includes near misses.
You can record incidents in your Incident Management System (IMS). Full incident records on your IMS are important for:
- providing safe, high-quality care
- meeting legal requirements
- reducing future risk
- informing continuous improvement.
Keeping accurate records
Everyone has a part to play in keeping accurate records.
To contribute to quality record-keeping, workers can:
- read and follow their service’s IMS policies and procedures
- find out who they should report to and how
- participate in training on reporting incidents and near misses
- record all incidents even when they're discovered after the fact or are already resolved.
To develop good record-keeping standards, managers should:
- deliver regular training
- provide examples of good record-keeping
- record incidents even where they've already been resolved.
What to include in an incident record
It's important to include the right details in an incident record.
Aged care workers should understand their service's policies and systems. Service managers should train and prepare workers so that they know what to do.
After you've recorded the incident, ask yourself: Would someone who didn't see the incident be able to understand this record?
When entering the incident, ask yourself Who, What, Where, When and How.
- Who's making the record?
- Who's involved?
- Who saw the incident happen?
- Who do you need to tell?
- What happened?
- What happened next?
- Are there any related previous incidents?
- Where did the incident happen?
- When did the incident happen?
- When was it recorded?
- How did the people involved respond?
- How was the resident supported?
- How have changes been made?
Once you've captured the basic information, it's time to provide more in-depth details. Use the following 7 key subjects as prompts:
- Provide details of the incident, including any allegations or suspicions.
- Provide your name or make sure the name of the person who reported the incident is recorded.
- Record who was involved in the incident.
- Record who the incident has affected.
- Note if there are related incidents. This helps establish any patterns.
What action has been taken?
- Outline the assessment and investigation.
- Document actions and outcomes.
Consultation and notification
- Describe consultations with key people involved.
- Identify whether you need to notify third parties.
- Assign tasks to the relevant people.
You can use the Understanding key details work tool to know what to include in each incident record. This work tool expands on the 7 key subjects.
Identifying incident patterns
Some incidents can seem minor, but the level of harm increases if they happen often.
It's important to record all incidents, no matter how minor they seem, so that you can identify and resolve patterns.
Privacy and confidentiality
IMS records must remain confidential. To protect the privacy of aged care users, store all personal information securely.
When you need to share information within your service or with other parties, follow privacy restrictions as laid out in:
- the Aged Care Act 1997 – Section 62-1
- the Privacy Act 1988
- the Australian Privacy Principles.
Updating incident records
You should update incident records as new information becomes available and as you respond to the incident.
Retaining incident records
Service managers must:
- keep all incident records for 7 years after the incident was identified
- have controls in place to maintain the privacy and confidentiality of all incident information
- keep related records, such as letters, together with the incident records.
Find out about our upcoming facilitated workshops.
For employees of Australian Government funded aged care providers, we have a free online education service available. Go to our education portal Alis. There you'll find:
- modules covering reportable incidents
- the 8 reportable incident types.
The information contained on this page provides general guidance.
It's your responsibility to be aware of your legislative requirements.