Defensible Documentation in Home Care

Overview

This training workshop will delve into the fundamental principles and practices of defensible documentation. Attendees will gain a deep understanding of the regulatory landscape governing documentation in home care, learning how to navigate complex requirements with confidence. Through interactive discussions and case studies, attendees will uncover strategies for creating clear, concise, and legally sound documentation that accurately reflects patient assessments, interventions, and outcomes.

Learning Outcomes

By the end of this very interactive training session, you will learn:

•   Describe legislative and legal considerations regarding documentation in-home care.
•   Outline the regulatory requirements regarding documentation (Aged Care Quality Standards and NDIS Practice Standards).
•   Describe the principles of effective documentation.
•   Select and apply the key recognised documentation methodology ISBAR, SOAP & DAP for documentation.
•   Describe the style of documentation required for the Aged Care Quality Standards in relation to referrals, reporting, mutual obligation and other purposes.
•   Develop outcome-based documentation that supports consumer choice, independence and quality of life.
•   Identify key aspects of documentation through case studies.
•   Summarise considerations in relation to documentation including:
  • Electronic records.
  • Streamlining documentation without sacrificing accuracy.
  • Documenting using objective methods.
  • Consumer rights and safety.
  • …