Use this checklist to assess your current documentation risk before the Aged Care Quality and Safety Commission assesses it for you. Seven compliance dimensions, structured for quality and governance leads.
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The checklist is structured around seven documentation risk dimensions — the areas most commonly flagged in Aged Care Quality and Safety Commission audits, SIRS reviews, and complaint investigations. Each dimension includes a set of audit-style questions you can apply to a sample of your current records to identify gaps before an external review does.
Use it as a standalone internal audit tool, a pre-assessment readiness check, or as a framework for a quality improvement conversation with your governance or clinical team.
Do records establish precise time references? Are notes completed during or immediately after the shift? Are observations person-specific rather than templated?
Do incident-related notes establish: the time of awareness, pre- and post-incident condition, immediate action taken, who was notified, and follow-up initiated?
Do shift notes reference the person's goals? Do records show whether care plan activities were completed? Is there evidence that concerns are escalated and followed up?
Do records show the person's choices, preferences, and participation — or only the tasks completed by workers? Are refusals documented with context and follow-up?
Can auditors trace an incident identified in one note through subsequent records? Is the follow-up trail visible across shifts? Are resolved incidents closed in the record?
Are medication records complete and contemporaneous? Are PRN administrations documented with indication, dose, and effect? Are refusals recorded with clinical response?
Do your documentation systems produce consistent records at the point of care? Are there systematic gaps that appear across multiple workers or shifts? Is there a quality review process?