frequency and detail to improvements are identified which relate to identification (which was corrected on the day 90 days comply with legislation the standard of documentation. of audit). and guidelines. Criterion 1.3.6.1 PA Low The previous audit noted that several Care was not documented according to policy Ensure clinical care interventions were not being documented in three of the seven clinical records is documented The provision of services to manage all residents’ needs including reviewed, which included (1) no according to policy. and/or interventions are medical needs where appropriate. A documentation of a resident’s weight on consistent with, and review of seven clinical records confirmed admission; (2) initial assessments for one contribute to, meeting that further improvement is required to resident not being dated and signed by the 90 days the consumers' address incomplete documentation. assessing staff member; and (3) a assessed needs, and physiotherapy intervention specified by a desired outcomes. physiotherapist was not documented in the resident’s plan of care (although staff were carrying out the physiotherapist’s treatment order).
frequency and detail to comply with legislation and guidelines. improvements are identified which relate to the standard of documentation. identification (which was corrected on the day of audit). 90 days Criterion 1.3.6.1 The provision of services and/or interventions are consistent with, and contribute to, meeting the consumers' assessed needs, and desired outcomes. PA Low The previous audit noted that several interventions were not being documented to manage all residents’ needs including medical needs where appropriate. A review of seven clinical records confirmed that further improvement is required to address incomplete documentation. Care was not documented according to policy in three of the seven clinical records reviewed, which included (1) no documentation of a resident’s weight on admission; (2) initial assessments for one resident not being dated and signed by the assessing staff member; and (3) a physiotherapy intervention specified by a physiotherapist was not documented in the resident’s plan of care (although staff were carrying out the physiotherapist’s treatment order). Ensure clinical care is documented according to policy. 90 days
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