Put in place an information management system to manage records.

Put in place a system for managing information, including the clinical information system (Outcome 5.1), that:

• gives workers and others such as visiting registered health practitioners and allied health professionals, agency workers and approved providers access to the right information at the right time
• enables older people, supporters and others they want to involve, to access the information they need to receive quality care and services
• makes sure stored information is accurate and complete. This also applies to information that’s shared between services that provide support to the older person such as telehealth services.
• makes sure that you get informed consent (Outcome 1.3) to collect, use and store older people’s information. You also need informed consent to disclose older people’s information with other people or organisations. This includes assessment information. If an older person withdraws their consent, record and communicate this.
• integrates information from different sources where needed, such as information from hospitals
• manages cyber security risks (Outcome 2.4)
• has enough data storage for the records you need to keep.

The information management system, including the clinical information system, should be digital where possible. This will be specific to each provider. There should always be ways to access critical information when digital systems are offline. For example, you can:

• put in place processes to make information available offline
• put in place processes to record clinical information on paper during internet or power outages. 
   

Use your information management system to record information.

Use the information management system to make sure you securely manage any records at the service. This should be in line with your state or territory legislation and applicable privacy laws. Use the information management system during processes, systems and strategies to do with:

• choice, independence and quality of life (Outcome 1.3), transparency and agreements (Outcome 1.4). Make sure information about the older person’s care, services, and agreements and care commencing (whichever comes first):
  • is current, accurate, timely and easy to understand
  • supports the older person to make informed decisions
  • is accessible by workers
  • helps workers to partner with older people to make informed decisions based on accurate and timely information.
• human resource management (Outcome 2.9). Store information from possible candidates and existing workers accurately against their profile.
• assessment and planning (Outcome 3.1). Each older person’s care and services plan needs to include information about the risks associated with the delivery of aged care services. It also needs to include how workers can support older people to manage these risks (Outcome 2.4). Make sure you securely store information from assessment and planning and risks and use it to inform the systems for:
  • comprehensive care (Outcome 5.4)
  • safe and quality use of medicines (Outcome 5.3) and antimicrobial stewardship (Outcome 5.2)
  • clinical safety (Outcome 5.5)
  • infection prevention and control in the environment (Outcome 4.2) and when you deliver clinical care services (Outcome 5.2)
  • palliative care and end-of-life care (Outcome 5.7)
  • food, drink and the dining experience (Outcomes 6.1, 6.2 and 6.4).

Put in place a clinical information system. This should be digital if possible. Use it to record and manage older people’s clinical information. For example, transitions of care (Outcome 3.4), assessment and planning (Outcome 3.1) and medication management (Outcome 5.3). This will help you to deliver safe and quality care and services. Where possible, the clinical information system should also record Quality Indicator data. The guidance for Outcome 5.1 has more information on the clinical governance framework.

Workers need to monitor and record each older person’s preferences, function and changes during activities of daily living. For providers delivering aged care services in a residential care home, the guidance for Outcome 7.1 has more information on supporting older people with activities of daily living.

During transitions of care, make sure you give timely, current and accurate information about the older person to supporters, health professionals and organisations involved in the older person’s care, in addition to others the older person may want to involve, such as family and carers. Make sure you provide this information with the older person’s informed consent. The guidance for Outcome 3.4 has more information on coordinating aged care services. For providers delivering aged care services in a residential care homer providers, the guidance for Outcome 7.2 has more information on transitions.

For providers delivering aged care services in a home or community setting, information about the older person’s care, such as nutritional needs or activities of daily living, can be stored in the clinical sections of your database. This doesn’t need to be a dedicated clinical information system. Make sure information about a person’s safe delivery of aged care services is assessed and those involved in their care can access it. This includes associated providers.
 

Put in place strategies to help workers use the information management system well.

Make sure all workers and others involved in the older person’s care can access your information management system. Make sure their access to your system is appropriate to their role. This includes any system workers or others, such as Commission Quality Auditors, use. This also includes any policies and procedures. Check with workers and others that they can access the information management system. If they can’t, make sure you give them access.

Make sure policies and procedures support people to use your information management system. Make sure these are: 
 

• current and informed by the latest contemporary evidence-based practices
• regularly reviewed
• clear and accessible for workers and others involved in the older person’s care and services.

Provide workers with guidance and training on how to use the information management system (Outcome 2.9). This includes training to support digital skills if needed. This needs to be in line with: 

• the organisation’s policies and procedures
• workers’ roles and responsibilities

Make sure workers understand:

• their role in the information management system
• how to use the system to safely manage information about older people and their aged care services.

The guidance for Outcomes 2.8 and 2.9 has more information on workforce planning and human resource management.  
 

Monitor how well you use the information management system.

Regularly review your information management system to make sure it works well. Look for ways to improve the system.

To check if you’re managing information well, you can review:

• older people’s care and service plans (Outcome 3.1)
• complaints and feedback (Outcome 2.6a and 2.6b)
• incident information (Outcome 2.5)
• worker performance and how well they’re using the information management system. You can do this through quality assurance and system reviews (Outcome 2.9).
• policies and procedures.

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, be open about it. Share what went wrong with older people, their supporters and others they may want to involve, such as family, and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system.