Documentation Essentials

Clinical and support records must contain all aspects of a participants’ care and support. They must also meet legal requirements and industry standards in order to manage participant safety and quality risks.

Documentation can apply to every component of a participant’s record including a progress note/shift summary, consent form, a clinical finding or investigation. The objective of this training workshop is to orientate support staff and students to the clinical, support and legal guidelines for documentation within the NDIS. It will cover; what to document, how to document it, confidentiality and documentation by providers.

Good documentation will achieve many things.
For example it will:
• Ensure that a complete record of supports is created
• Substantiate decisions and management plans
• Support continuity of supports and show how supports are meeting NDIS goals
• Facilitate proactive and reactive risk management
• Help prevent and defend legal claims
• Provide useful information for quality improvement and research purposes
Remember: The test of a good documentation record is – will this record tell the whole story in a
year and prove that supports are aligning to what the NDIS want and meeting the participant’s goals?