Anc 0001 0009 0151

ANC.0001.0009.
0151
Anglican Retirement Villages Module VII – Assessment, Care Planning and Documentation
Module VII – Assessment, Care Planning and Documentation
Assessment, Care Planning

and Documentation
Procedures
Manual: Managing Care & Lifestyle Copyright ARV June 2012 Page 1 of 42
ANC.0001.0009.0152
Section 7.01 Assessment, Care Planning and Documentation Policy

Procedure ARV-CS-0701-Rev Jan12
Policy Documentation is a vital component of safe, ethical and effective writing practices,
regardless of the context of practice or whether the documentation is paper based or
electronic. Documentation will promote enhanced nursing care and facilitate
communication between nurses and the multidisciplinary team.
Standard Accurate and timely documentation will reflect care provided and meets professional,
legislative and agency standards
Accountabilities The Manager is responsible for the management of all procedures relating to
and Delegation assessment documentation and care planning within their facility. The Manager will
approve all delegated responsibilities given the skill and staffing mix of the facility.
The Clinical Leader is responsible for the implementation and monitoring of the ARV
assessment documentation and care planning procedures within their facilities.
The Clinical Leader is responsible for identifying an appropriate delegate to

continue/maintain those accountabilities in the absence of the Clinical Leader or if the
staffing model within the facilities warrants this delegation. For example on weekends,
afterhours and during any absence of the Clinical Leader.
Registered Nurses are accountable for all tasks identified within the documentation
management procedures as well as any delegation on any given shift from the Clinical
Leader or Manager to ensure the processes within the procedures are sustained.
Governance Professional documentation will:

• Comply with the ANMC standards
• Promote a high standard of care
• Promote evidence and continuity of nursing care
• Promote improved communication and dissemination of information between
and across service providers
• Promote and accurate account of assessment, care planning, treatment and
evaluation
• Improve goal setting and evaluation of care outcomes
• Improve early detection of problems and changes in health status
Nursing documentation provides accountability in record keeping describing the

expectations for nursing documentation in all practice settings. Nursing documentation
provides an account of judgement and critical thinking used in the nursing process,
assessment, diagnosis, planning, intervention and evaluation
Reviewed: Internal Reference Group, 21/12/2011

Approved: K. Rice, General Manager Care Services, 23/01/2012
ANC.0001.0009.0153
Section 7.02 Assessment and Care Planning Procedure

Standard Care delivered in residential settings is based on assessment and individual

preferences/needs within the parameter of funding models
Assessment - On or prior to admission a Registered Nurse is to interview the resident and/or their
Develop Interim representatives, review the ACCR, and complete the Resident Entry Status Form
(CF021), ICare users complete the Care Profile
Care Plan
The Resident Entry Status Form or iCare Care Profile is to be utilised as an interim care
plan. On admission photocopies of the interim Care Plan should be distributed at
“handover” to care staff responsible for caring for the resident. A photograph may be
attached to the plan to assist staff identify the new resident.
Care staff should refer to the above forms when delivering care to the new resident.
Responsibilities The Registered Nurse is responsible for:

• Assessing the resident, reviewing documentation and identifying assessments
to be completed.
• Commencing Compulsory ACFI assessments on day 8 of the resident’s
admission. (Should it be necessary to complete assessments before day 8, they
need to be reviewed and dated after day 8 to meet ACFI requirements.)
• Overseeing care delivery and ensuring all relevant care instructions are
communicated clearly to staff.
• Making sound clinical decisions based on assessed care needs.
• Completing assessments relevant to immediate care needs.
• Reviewing progress notes and relevant documentation.
• Completing all RN assessments and care plans.
Note: Assessments and care plans are multidisciplinary tools and should be
completed as a team effort to sustain a continuum of care across disciplines,
where appropriate.
Care staff are responsible for:

• Documenting either in the Progress Notes and/or on the relevant assessment
tools, care given prior to the development of the resident’s Care Plan. (See
attached flow chart for documentation).
• Completing monitoring charts/assessments as directed by the registered nurse.
ANC.0001.0009.0154
Develop Care Plan Care and service needs are identified from information gathered during assessment,
review of relevant documents, ACCR, discharge/referrals and other documentation.
Identified care and service needs are documented onto the care plan instruction. Goals
set are measurable.
The resident, representative and multidisciplinary team are integral to the development
of a meaningful and comprehensive care plan. Resident’s individual needs and
preferences are taken into account.
Residents must have a Care Plan developed within the first 28 days of admission.
Care Plan The Clinical Leader is responsible for:

Responsibilities • Ensuring only appropriately trained and competent staff develop care plans.
• Ensuring Registered Nurses oversee non Registered Nurses developing care
plans.
• Allocating the workload and responsibility for the development of care plans.
• Ensuring that care plans are completed within 28 days of a resident’s admission.
Staff responsible for writing the care plans are to:

• Review Progress Notes, relevant documentation and relevant assessment tools.
• Identify and document resident care needs.
• Identify and document care interventions to address care needs.
• Set measurable clinical goals to determine the effectiveness of the care
interventions.
• Work closely with all members of the multidisciplinary team in the development
of care plans.
• Ensure that all care plans are completed within 28 days of a resident’s
admission.
Develop Bedside Bedside Care Plans (CF025) or the iCare summary care plan may be utilised by facilities
Care Plan to facilitate delivery of care.
The Registered Nurse is responsible for:
• Completing the bedside care plan or iCare summary care plan.
• Ensuring that bedside care plans or iCare summary care plan are updated when
there is a change in the resident’s Care Plan.
Review and Definition:

Evaluate Care • A care plan review is defined as a brief overview of the residents' care needs.
Plan Care plan reviews are particularly pertinent when changes occur in a specific
area of care e.g. pain management.
• A care plan evaluation can be defined as a holistic and comprehensive look at all
care strategies and their effectiveness in meeting the resident's overall care
needs. Typically, care evaluations should involve key members of the care team,
the resident and/or their representative.
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When to Evaluate Care plans are to be fully evaluated every 12 months and more frequently to
correspond with a change in the residents care needs.
Care plans must be evaluated when an ACFI is re appraised.
Any change to a Resident’s care needs should be immediately entered into the care
plan.
Additional care plan review, evaluations and/or updates should be made when the
resident develops a significant change to their health status due to;
• An acute critical event e.g. CVA.
• An incident that significantly alters their overall care needs.
• The deterioration of existing illness.
• The diagnosis of a new illness.
• The development of palliative care needs.
This change may be identified during the implementation of a Significant Episode Care
Plan SECP (CF028).
How to Evaluate Staff responsible for evaluating care plans are to:
• Visually assess the resident:
• Re-do any appropriate assessments to help inform the Care Plan.
• Review resident Progress Notes and other relevant clinical information.
• Discuss the resident’s care needs with all involved in delivering care to the
resident and if applicable the resident and/or their representative. If indicated,
conduct a care conference check that documented care needs are current.
• Check that goals are being met.
ACFI The Facility Manager/Clinical Leader is responsible for:

Responsibilities • Allocating staff responsibility for completing and submitting ACFI appraisals.
• Ensuring only appropriate trained Registered Nurses, Clinical Leaders and
Managers assessed as competent are to appraise residents ACFI domains.
• Ensuring all ACFI appraisals are completed and lodged by the due date.
ACFI ACFI Appraisal and Assessment Pack

www.health.gov.au/internet/main/publishing.nsf/Content/ageing-assessment
The person responsible for completing the ACFI Appraisal pack is to review:
• Progress notes.
• All documentation including Medical notes/ACCR & any hospital transfer
documents for diagnoses and supporting information.
• Information gathered from Clinical assessments, treatment forms & medication
charts.
• Care plans and evaluate and complete as required.
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The person responsible for completing & submitting ACFI claims is to:
ACFI-Records
• Compile the ACFI appraisal pack including any specific material/evidence/
assessments and file in designated ACFI filing cabinet.
• Ensure all ACFI appraisals are completed by the set due date & lodged with
Medicare.
• Check that lodgement has been accepted
Note: When utilising assessments for ACFI purposes, please note that these
assessments must have been attended within the 6 months prior to submission of the
ACFI claim

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Section 7.03 Guidelines for Completing Assessments and Care Plans

Standard To identify and complete the necessary assessments and care plans for the resident,
relevant to their assessed care needs to ensure the appropriate delivery of care
Scope All residents admitted to an ARV RACF must have the following documents completed
on admission (within 7 days) or as soon as possible thereafter if indicated
The Cognition Assessment consists of:

• CF105C Wandering Behaviour Assessment & Care Plan
• CF105D Verbal Behaviour Assessment & Care Plan
• CF105E Physical Behaviour Assessment & Care Plan
• iCare : Behaviour Assessment
• ACFI 7 Behaviour Record Wandering
• ACFI 8 Behaviour Record Verbal
• ACFI 9 Behaviour Record Physical
The following documents can be completed/used at any stage of the Residents stay at
ARV:
• CF105A Cognitive Assessment Record
• CF105B Cognition Reference Tools
• CF130F Exceptional Care Plan – Cognition
PAS, Cornell and MMSE forms are also related to this Pack.
Sleep Assessment consists of:

• CF113A Sleep Assessment and Care Plan
• CF113B Sleep Pattern Record
• iCare: Sleep Assessment
Communication Assessment consists of:

• CF114 Communication Assessment and care plan
• iCare: Hearing Assessment, Vision Assessment, Speech and Language
Assessment and Reading and Writing Assessment
The Hygiene Assessment consists of:

• CF111 Hygiene Assessment and Care Plan
• iCare: Personal Hygiene Assessment
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Scope cont. Nutrition Assessment consists of:

• CF112 Nutrition assessment and Care Plan
• iCare: Nutrition and Hydration Assessment
• Weight Chart
The following documents can be completed/used at any stage of the Residents stay at
ARV:
• Fluid Balance Chart
• iCare: Fluid Intake Chart and Fluid Output Chart
Pain Assessment consists of:

• CF115A Pain Assessment and Care Plan
• CF115B Pain Monitoring Record
• CF115C Pain Treatment Plan Record
• iCare: Pain Assessment and Pain chart
Skin Assessment consists of:

• CF116 Skin Assessment and Care Plan
• iCare: Skin Integrity Assessment, Braden Risk Assessment Scale, Wound
Assessment and Wound Chart
Toileting and Continence Assessment consists of:

• CF117A Toileting and Continence Assessment and Care Plan
• CF 117B Continence Record
• iCare: ACFI 5 Urinary Continence and Bowel Continence
• iCare: Urinary Assessment and Bowel Assessment
The Medication Assessment consists of:

• CF131A Medication Assessment and Care Plan
• ICare: Medication Administration and Self Medication Assessment
The following documents can be completed at any stage of the Residents stay at ARV:
• CF131B Exceptional Care Plan – Medication
• CF131C Psychotropic Medication Review
Oral and Dental Assessment consists of:

• CF120 Oral and Dental Assessment and Care Plan
• iCare: Oral and Dental Assessment and Oral and Dental Management Plan
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Scope cont. Falls Assessment consist of:

• CF130A Mobility Assessment and Care Plan
• CF130D FRAT
• CF130F Physiotherapy Assessment and Treatment Plan – Physio only to
complete
• iCare: FRAT, Mobility Assessment, Physiotherapy Assessment (P/T only)and Falls
Risk Management Plan
Diversional Therapy Assessment (completed by Diversional Therapists) consist of:

• CF132 Leisure and Lifestyle Assessment and Care Plan
• CF132A My Family and Social History
• CF132B Religious, Spiritual and Cultural Assessment and Care Plan
• CF132D DT Assessment and Care Plan
• iCare: Activity Therapy Assessment -Preferences/Pursuits/Abilities and Key to
Me – Social History and Emotional Support
Who can These are multidisciplinary assessments and can be contributed to by:
Complete It • RNs (CF114 only to be completed by RN or Sensory Loss RN)
• Care Staff
• Doctors
• Other Allied Health
• Sensory Loss RN
• Physiotherapists
• Allied Health Professionals
This should show a continuum of care across relevant disciplines with no duplication of
assessment or documentation.
Source Relevant assessment information may also be obtained from:

Documents • Documents on admission
• Progress Notes
• Medical Notes
• ACAT assessments
• Medication Charts
• Other relevant Care Plans
• Hospital admission/discharge documentation
• Health Professional/Consultant notes, e.g. geriatrician, psychogeriatrician, etc.
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Filing Documents must be filed in the Care Plan section of the Residents Progress Notes.
Yellow Tab – General Assessments and Care Plans including: hygiene, nutrition, sleep,
communication, skin, toileting, Pain and Oral and Dental Assessments and Care Plans.
Green Tab – Medication Assessment and Care Plan Pack, medication incidents.
Red Tab – Cognition assessment, care plans and tools.
If the document becomes too busy with multiple updates or is full, a new Assessment &
Care Plan Pack should be completed with the previous form(s) attached or archived.
ACFI Pack ACFI Pack Documents

Documents /
The following documents in this Pack must be photocopied/printed when
Requirements
completed/updated and added to the ACFI Pack if claiming:
• Wandering Behaviour Assessment and Care Plan
• Verbal Behaviour Assessment and Care Plan
• Physical Behaviour Assessment and Care Plan
• ACFI 7 Behaviour Record Wandering
• ACFI 8 Behaviour Record Verbal
• ACFI 9 Behaviour Record Physical
• PAS
• Cornell
• Pain Assessment and Care Plan
• Pain Monitoring Record
• Pain Treatment Plan and Record
• Skin Assessment and Care Plan
• Toileting Assessment and Care Plan
• ACFI 5 Continence and Bowel Record
• Complex Health Care Assessment and Care Plan
Colour Coded Pen The Care Recipient may be re-assessed and the Care Plan updated several times on the
for Multiple one form. For this reason when updating any of the forms contained in this Pack you
need to use a colour coded pen:
Assessments
• Black Pen – First assessment: use black pen to sign, write designation and date.
• Blue Pen – Second assessment use blue pen sign to sign, write designation and
date.
• Red Pen – Third assessment use red pen to sign, write designation and date.
Additional assessments after that will require new Assessments and Care Plan Packs to
be completed.

ANC.0001.0009.0161
Anglican Retirement Villages Module VII - Assessment, Ca re Planning and Document ation
ACFI, Admission, Assessment, Care Plan, Documentation and Review Process
ACFI Pack Assessments Progress Notes

1-28 days-----1.i +----Ongoing
and Care Plan
ACFI Answer Appraisal Deviation from Care
Pack Plan Hospit alisat ion
Sign ificant Episode Care

Evidence of diagnoses Plan
e.g. ACCR/GP notes RESIDENT Exception
ACFI Admission CARE 24 Hour Report
Reporting
Copies of: Reportable Incident
• Medicat ion cha rt Resident Incident
• ACFI compu lsory Family/Resident

Major Change in concerns
assessments 3 -7 days------1 Resident Condition - - -Ongoing
• PAS and Cornel not GP int erventions
requ ired if score "A" M INIMUM
Any other evidence to Weekly High Care
support complex care Documentation for
claims Monthly Low Care
ACfl Reyjew
1-7days documentation
to reflect changes
Updat e relevant
assessment s
• Behaviours 7 days
• Continence 3 days
Manual: Managing Ca re & lifestyle Copyright ARV June 2012 Page 11 of 42

ANC.0001.0009.0162
Care Administration & Care Correspondence When to be ACFI PACK Responsibility

Completed
Care Conference Notification (CF024) When Required - RN

No iCare Equivalent – Use paper record (CF024)
iCare Checklist for Admission for New Resident Compulsory - RN

on Admission
No ARV Equivalent.
Respite Confirmation Letter (CF060 and CF060A) When Required - RN

No iCare Equivalent – Use paper record (CF060 and CF060A)
Resident Consent Form (CF027) Compulsory - RN

on Admission
Resident Details Form (CF026) Compulsory - Admin / RN

on Admission
Use: Input data into iCare Resident Details Section
Resident Entry Status (CF021) Compulsory - RN

on Admission
Use: iCare Care Profile
Resident Transfer Form (CF016) When Required - RN / Person –

Use: iCare Resident Transfer Form in-Charge
Cognitive, Behaviour and Restraint Management
Bed Rail Assessment Form (CF049) When Required - RN

Use: iCare Bed Rail Assessment
Cognition Reference Tools (CF105B) When Required -

Use: iCare Mini Mental state Examination (MMSE) RN
Use: iCare Delirium - Confusion Assessment Method (CAM)
Cornell (CF 101) When Required Compulsory RN

Use: iCare Cornell If claiming
PAS (CF100) When Required Compulsory RN

Use: iCare PAS If claiming
Restraint Application and Release Log (CF014) When Required - RN

Use: iCare Restraint Chart
Restraint Authorisation (CF014) When Required - RN

Resident Identification Form (CF015) When Required - RN

Wandering Behaviour Assessment /Care Plan (CF105C) When Required - RN

Verbal Behaviour Assessment/Care Plan (CF105D)
Physical Behaviour Assessment/Care Plan (CF150E)
Use: iCare Behaviour Assessment
ANC.0001.0009.0163
Cognitive, Behaviour and Restraint Management cont.
Behaviour Record for Wandering (ACFI 7) When Required Compulsory RN

Use: iCare Behaviour Record Wandering (ACFI) If claiming
Behaviour Record For Verbal Behaviour (ACFI 8) When Required Compulsory RN

Use: iCare Behaviour Record Verbal (ACFI) If claiming
Behaviour Record for Physical Behaviour (ACFI 9) When Required Compulsory RN

Use: iCare Behaviour Record Physical (ACFI) If claiming
iCare Behaviour Chart When required - RN

No ARV Equivalent
Continence / Bowel Management
Bowel Monitoring Chart (CF032) When Required - RN

iCare Bowel Chart
Continence Record ACFI 5 (CF117B) When Required Compulsory RN

Use: iCare Urinary Continence Form (ACFI) If claiming
Use: iCare Bowel Continence Form (ACFI)
iCare Fluid Output Chart When Required - RN

iCare Urinary Chart
Toileting Assessment/Care Plan (CF117A) Compulsory - RN

Use: iCare Urinary Assessment on Admission
Use: iCare Bowel Assessment
End of Life Documentation
Advanced Care Plan (CF134) When Required - RN /CNC

No iCare Equivalent – Use (CF134)
Comfort Care Plan (CF133B) When Required - RN /CNC

No iCare Equivalent – Use (CF133B)
End of Life Pathway (CF133A) When Required - RN /CNC

No iCare Equivalent – Use (CF133A)
Referral to Palliative Care CNC (CF134) When Required - RN

Diversional Therapy
Leisure Assessment/Plan (CF132c) Compulsory - DT/RAO

on Admission
iCare Activity Therapy Assessment – Preferences / Pursuits /
Abilities
My Family and Social History (CF132a) When Required - DT/RAO/

iCare Key to Me – Social History / Emotional Support Resident/
Family
ANC.0001.0009.0164
Doctors: Forms (Encourage doctors to use iCare)
Medical Practioner Notes (CF002) - - Doctor

Use: iCare Progress Notes
Medical Report RACF (CF020) - - Doctor

Use: iCare Medical History
General Care
iCare Chest and Abdomen Assessment When Required -

No ARV Equivalent
Communication Assessment/Care Plan (CF114) Compulsory - RN (Sensory)

on Admission
Use: iCare Hearing Assessment
Use: iCare Vision Assessment
Use: iCare Speech and Language Assessment
Use: iCare Reading and Writing Assessment
Dental Transfer Form (CF091) When Required - RN

Exceptional Care Plan – Complex Procedures (CF118) When Required Compulsory if RN

Use: iCare Complex Health Care Assessment Claiming
General Observations (CF009) When Required - RN

Use: iCare Vital Signs Chart
Glasgow Coma Scale (CF039) When Required - RN

Hygiene Assessment/Care Plan (CF111) Compulsory - RN

on Admission
iCare Personal Hygiene Assessment
iCare ADL Chart When Required - RN

No ARV Equivalent
Multi-Purpose Chart (CF006) When Required Compulsory if RN

Use: iCare Blood Glucose Chart Claiming
iCare Blood Pressure Chart
Oral & Dental assessment/care plan (CF120) When Required - RN

Use: iCare Oral and Dental Assessment
Use: iCare Oral and dental Management Plan
Sleep Assessment/Care Plan (CF113A) Compulsory - RN

on Admission
Use: iCare Sleep Assessment
Sleep Pattern Record (CF113B) When Required - RN

ANC.0001.0009.0165
Incident Management / Reportable Assaults/

Missing Residents
Resident Incident (CF005) When Required RN /Person-in-

iCare Accident / Incident Report Charge
Medication Incident Form (CF042) When Required RN /Person-in-

iCare Medication Incident Report Charge
Missing Resident Record Report (CF017) When Required RN /Person-in-

No iCare Equivalent – Use paper record (CF017) Charge
Record of Alleged or Suspected Mandatory Reportable Assaults When Required Manager

(CF011)
Register of Alleged or Suspected Assaults (CF011A) When Required Manager

No iCare Equivalent – Use paper record (CF011A)
Infection Control
Infection Reporting Criteria (CF028) Ongoing Monthly - Clinical Leader

No iCare Equivalent – Use paper record (CF028) Reporting
Infection Incidence Prevalence Anti-Microbial Utilisation Ongoing Monthly - Clinical Leader

(CF029) Reporting
Outbreak: Standard Letter to Families (CF071A) When Required - Clinical Leader

No iCare Equivalent – Use (CF071A)
Outbreak: Standard Letter to Doctor (CF071B) When Required - Clinical Leader

Outbreak Over: Standard Letter to Residents and Families When Required - Clinical Leader
(CF071C)
No iCare Equivalent – Use (CF071C)
Letter: Illness Information Letter (CF071D) When Required - Clinical Leader

No iCare Equivalent – Use (CF071D)
Medication Management
Emergency Medication Record of Stock Use (CF137) Ongoing - RN

No iCare Equivalent use (CF137)
Emergency Medication – Stat Box Inventory (CF136) Ongoing - RN

Insulin Therapy Protocol (CF023) When Required - RN

Medication Assessment/Care Plan (CF131A) Compulsory - RN

on Admission
Use: iCare Medication Administration
Use: iCare Self Medication Assessment
ANC.0001.0009.0166
Medication Management cont.
Medication Chart (Primary Chart) Compulsory Compulsory if Doctor / RN

on Admission Claiming
No iCare Equivalent – Use paper record.
Medication Incident Form (CF042) When Required - RN /Person-in-

iCare Medication Incident Report Charge
Mobility and Falls
iCare Berg Balance Scale (New Form) When Required - Physiotherapist
iCare Falls Risk Management Plan (New Form) When Required - Physiotherapist
iCare 10 metre Walk Test (New Form) When Required - Physiotherapist
ICare Modified Elderly Mobility Scale (New Form) When Required - Physiotherapist
iCare Physical Mobility Scale(New Form) When Required - Physiotherapist
iCare Tinetti Balance and Gait Assessment (New Form) When Required - Physiotherapist
Falls Risk Assessment Tool (CF130D) Compulsory _ RN/Physio

Use: iCare Falls Risk Assessment Tool on Admission
Mobility Assessment and Care Plan (CF130A) Compulsory - RN/Physio

on Admission
Use: iCare Mobility Assessment
Physiotherapy Assessment and Treatment Plan (CF130F Compulsory - Physio

on Admission
Use: iCare Physiotherapy Assessment
Nutrition, Hydration and Weight Management
Nutrition Assessment/Care Plan (CF112) Compulsory - RN

on Admission
Use: iCare Nutrition and Hydration Assessment
Fluid Balance (CF030) When Required - RN

Use: iCare Fluid Intake Chart
Use: iCare Fluid Output Chart
Weight Management Form (CF090) When Required - RN

Use: iCare Weight Chart
Pain Management
Pain Assessment/Care Plan (CF115A) Compulsory Compulsory RN

on Admission
Use: iCare Pain Assessment If claiming
Pain Monitoring Record (CF115B) When Required Compulsory RN / Physio

Use: iCare Pain Chart If claiming
Pain Treatment Plan and Record (CF115C) When Required Compulsory RN/Physio
No iCare Equivalent – Use paper record (CF115C) If claiming
ANC.0001.0009.0167
Referral Forms
Allied Health Referral Form (CF022) When Required - RN

Bright Minds Referral Form When Required - RN

No iCare Equivalent use paper referral form.
BPR Referral Form (CF200) When Required - RN

Skin Care and Wound Management
Skin Assessment/Care Plan (CF116) Compulsory Compulsory RN

Use: iCare Skin Integrity Assessment on Admission If claiming
Use: iCare Braden Risk Assessment Scale
Wound Assessment and Treatment Plan (CF036) When Required Compulsory RN

Use: iCare Wound Chart If claiming
Use: iCare Wound Assessment
Miscellaneous Forms
Approved Abbreviations List (CF099) - - -

Use: iCare Abbreviation List
Continuous Improvement Register (CF008) When Required - Manager

Continuous Improvement Work Plan (CF007) When Required - Manager

Clinical Records Filing Order (CF018) Ongoing - Administration

Use: Clinical Records Filing Order (not iCare Document)
Feedback Response and Management Form (CF019) When Required - Manager

Investigation Results (CF004) Ongoing - Clinical Leader

No iCare Equivalent – Use paper record (CF004) RN
RACF Audits As per Schedule - Clinical Leader

No iCare Equivalent – Use Current Schedule and Audit Tools Manager
Signature Register (CF044) Ongoing - Clinical Leader

(If the PAS or CDS is being utilised as assessments that will assist an ACFI application, the Dr will need to support
these assessments by providing documented evidence in the Medical Progress Notes to support a diagnosis of
Dementia, Psychiatric or Behavioural diagnosis, or a diagnosis of Depression. In the case of Depression/Psychotic
and Neurotic disorders – the diagnosis will need to be within the previous 12 months)
ANC.0001.0009.0168
Section 7.04 Care Conferencing Procedure

Standard To facilitate an effective care conference within the multidisciplinary environment.
Establish Need to Care conferences should be conducted/considered:

Conduct Care • For all new residents 6 weeks post admission and,
Conference
• Annually as part of the review process
• For all residents with new complex behaviours and/or care needs;
• When there is a significant change in a residents care needs; or
• When requested by a resident and/or their representative.
• Palliative care plans
Ensure A Registered Nurse/Clinical Leader should identify and facilitate the attendance of key
Attendance of personnel at care conferences.
Key Personnel
Key personnel may include the:
• Resident and/or their representative;
• Care Service Employee who provides regular care;
• Physiotherapist;
• Diversional Therapist or Recreational Activities Officer;
• Registered Nurse responsible for developing the resident’s Care Plan and
oversighting the residents daily care; and
• Medical Practitioner.
Prepare For Care The Registered Nurse/Clinical Leader responsible for facilitating the care conference
Conference should ensure:
• Attendees are notified in writing of the time and venue of the care conference,
the Care Conference Notification Form (CF024) should be utilised for this
purpose;
• The conference venue is booked;
• All clinical documentation is up-to-date and available for the conference; and
• Any issues or problems that may need to be discussed are identified. The Care
Conference Notification Form (CF024) can be utilised for this purpose.
Facilitate Care The Registered Nurse/Clinical Leader is responsible for facilitating the care conference
Conference and should ensure:
• All participants are encouraged to provide input and contribute to the decision
making process; and
• Agreed conference start and finish times are kept;
ANC.0001.0009.0169
Document The Registered Nurse/Clinical Leader responsible for facilitating the care conference
Meeting should document in the Progress Notes:
Outcomes • That the case conference has been conducted, who attended; and
• Key issues discussed.
Evaluate and The Registered Nurse/Clinical Leader responsible for facilitating the care conference
Update Care Plan should evaluate and update the Care Plan to reflect care conference outcomes.

ANC.0001.0009.0170
Section 7.05 Management of a Significant Episode Care Plan

Procedure
Standard The Significant Episode Care Plan (SECP) (CF028) is a document designed to review,
record and communicate the short term interventions required to meet the change in a
resident’s care needs, resulting from events such as (but not limited to):
• A fall
• Acute respiratory infection
• Gastroenteritis
• Severe UTI
• General deterioration
• Return from hospital/procedure
It has been developed in response to an initiative proposing to reduce reviews of

resident Care Plans in RACF from 3 monthly to yearly.
Aim To ensure appropriate follow up and handover of information that contributes to the
care of a resident by:
• Enabling assessment, monitoring and review of the care required by a resident
after a significant episode on a daily basis by an RN.
• Providing a simple, streamlined method for communicating the resident’s care
needs to care staff on a daily basis during this period.
• Ensuring that the care needs of residents who require additional interventions
due to a significant episode do not ‘fall through the cracks’ as a result of the
review of Care Plans reduced from 3 monthly to yearly.
• Providing a mechanism by which an RN can evaluate a resident’s care needs on
a daily basis during a significant period and determine whether a full care plan
review and ACFI assessment for an increase is required.
• Providing a means for an RN to assess whether the short term strategies they
are implementing are working, and to fix problems quickly if they are not.
RN Initiates SECP 1. RN advised of resident having a significant episode.
2. RN obtains copy of SECP and completes relevant details on top of form (resident
details, diagnosis, and date of significant episode).
3. RN adds resident’s Addressograph label to the Index in SECP folder.
4. RN documents in progress notes that a SECP has been commenced and the reason
for its initiation
ANC.0001.0009.0171
RN Review of 5. RN reviews resident’s care needs as soon as possible immediately following the
Care Needs significant episode.
6. RN makes decision regarding care required for that resident for the next 24 hours
ONLY.
7. RN completes SECP - highlights care required:

• ADLs on page 1
• Exceptions on page 2 (Other)
8. RN signs SECP at the bottom of form for the relevant date. This verifies that the
RN has reviewed the resident daily.
SECP Folder and 9. RN places SECP in SECP folder for Handover. All SECP’s should be stored together
Handover in a separate, specific folder for easy access for all staff. The Index (CF029) is
placed at the front of the folder to track residents on a SECP. The folder should be
kept wherever Handover is completed in each Facility. Review of SECP’s should
become part of the Handover procedure.
RN Completes 10. RN completes steps 5-7 for each day during the review period (which varies but
SECP Assessment may be for up to 7 days).
Care Plan Update 11. RN is to decide whether Care Plan and ACFI need to be reviewed and updated.
12. RN documents in progress notes that that SECP has been completed and the
outcome of the SECP
Filing of SECP 13. At the end of the review period (which may be up to 7 days), the SECP to be filed
in the residents clinical file once Care Plan is updated OR review period for episode
is complete.
Delegation 14. The Clinical Leader of a Facility is to delegate responsibility for completing a SECP if
an RN is not on duty.
15. Note: The review period may vary but can be for up to 7 days after the significant
episode. The SECP can be ceased by the RN at any time during the 7 days if the
resident’s main Care Plan has been updated or there is no change to the resident’s
pre-significant episode condition.
ANC.0001.0009 .0172
Anglican Retir em ent Villages M o dule VII - Assessment, Care Plann ing and Docu ment ation
SECP The Significant Episode Care Plan (SECP) drives documentation and care planning for
the resident during the period immediately follow ing the significant episode.
Suspected change in
care needs
r-unsure
Use SECP
No~
Yes
I
Update Care Plan and

Bedside Care Plan
ACFI Review
(_EN-D)
The resident' s exist ing Care Plan and Bedside Care Plan (if used) remain in place during
the period in w hich the SECP is being completed. The SECP complements these
documents by providing a means for review of care needs for a specific purpose and
period of time (up to 7 days). The SECP show s what needs to change in the care of the
resident for a particular day . It tells the care staff w hat to do on that day. The care
provided by the care staff is documented in the resident' s Progress Notes and other
relevant Assessment tools (e.g. Behaviour, Pain, etc).
If the care required by the resident changes w ithin the period of time covered by the
SECP (this varies but can be up to 7 days), the resident's Care Plan needs to be review ed
and updated and ACFI commenced if an increase is obtainable.
All residents w ho have a significant episode are rev iew ed by the RN on the day of the
significant episode. An appropriate Significant Episode Care Plan is implemented to
ensure that:
• The resident receives timely, appropriate care for their care needs on each day .
• These care needs are communicated to the right people at the right t ime (e.g.
carers, other Facility staff, at Handover).
• The resident's main Care Plan is review ed and the ACFI updated if necessary.
M anual: M anaging Care & Lifestyle Copyright ARV Jun e 2012 Page 22 o f 42
ANC.0001.0009.0173
SECP cont. The SECP:

• Demonstrates whether an existing Care Plan is valid or not.
• Provides evidence that there has been an evaluation of a resident’s Care Plan in
response to a change in care needs.
• Provides evidence that the care of a resident was managed and how it was
managed through the period immediately following a significant episode.
• Can be used as a handover tool between staff shifts.

ANC.0001.0009.0174
Section 7.06 Management of 24 Hour Reporting Procedure

Standard For the management of a significant event in care plan the “24 Hour Report” is to
capture, for the purpose of communication, important care “exceptions” that relate to
a resident’s physical, social or spiritual well-being, enabling the implementation of
appropriate and timely interventions and ensuring continuity of communication across
shifts.
Defining Care A care “exception” is defined as an action or event involving the resident that otherwise
“Exception” would be outside their “normal” day to day life or routine that staff on following shifts
should be made aware of. For example, a fall or episode of unusual behaviour would be
considered a care “exception”.
Management of Format:
the 24 Hour
The 24 Hour Report form (CF010) is used to record information in the 24 Hour Report.
Report/iCare
Handover Report All written entries into the 24 Hour Report entries must be brief.
A comprehensive account of the care “exception” must be recorded into the resident’s
progress notes and, if appropriate, their care plan. The 24 Hour Report should not be
considered a substitute or replacement for progress notes.
Each entry into the 24 Hour Report must include;

• The date and time of entry,
• The full name of the resident for which the information relates to,
• A brief account of the care “exception” and,
• The name, signature and designation of the person the writing the entry.
Location of the 24 Hour Report:
The 24 Hour Report is to be located at the main nurses’ office, clinic or a location
designated by the facility as being the most appropriate. Where appropriate, more
than one 24 Hour Report folder can be maintained. For example, each Wing of a village
might have a separate 24 Hour Report folder.
Select Handover Sheets from the Main Menu.
Select either “All Residents at the selected Facility” OR “Select Location” if your facility
is using iCare locations.
Select Date Range “In the previous” and enter an appropriate timeframe.
ANC.0001.0009.0175
Management of The “Contents” of the handover should contain; Progress Notes, Forms and Charts (Care
the 24 Hour Plan Interventions are optional inclusions in the Handover Report.)
Report/iCare
Progress Notes – this option will return all Progress Notes, for the selected Residents
Handover Report within the previously nominated date and/or time range.
cont.
Forms & Charts – this option will return all completed Assessment Forms, for the
selected Residents within the previously nominated date and/or time range.
Care Plan Interventions – this option will return all Care Plan Interventions, from the
selected Residents active Care Plans, within the previously nominated date and/or time
range.
Management of Responsibility: The Clinical Leader, Registered Nurse or person in charge of shift is
the 24 Hour responsible for reading and communicating all care “exceptions” to staff prior to them
commencing duties.
Report/iCare
Handover Report The 24 Hour Report must be signed by the designated person in charge of the shift to
confirm that they have read, actioned (where appropriate) and communicated relevant
information to staff.
iCare: The Clinical Leader/Registered Nurse or person in charge of the shift is

responsible for reading and communication all care exceptions from the iCare handover
report each shift to staff prior to them commencing duties
Information to be All entries into the 24 Hour Report or iCare handover report must be a brief description
included into the of the care “exception”. Examples of what should be recorded into the Report include:
24 Hour Report • The resident experiences a significant or critical health event i.e. heart attack or
stroke.
• The resident experiences a fall, skin tear or is involved in any other incident.
• The resident is diagnosed with a new condition.
• The resident is prescribed a new medical treatment or therapy.
• An existing treatment or therapy is changed or ceased.
• The resident absconds from the facility.
• The resident is aggressive towards others or develops changes in their
behaviour.
• The resident develops a change to their health or care status i.e. asthma
worsens.
• The resident experiences the loss of a spouse, family member, friend or other
significant person.
• The Death of a Resident
• The resident (or their representative) expresses a concern or discloses
information that could have an effect on the resident i.e. suicidal thoughts.
• The resident develops a change to their social, emotional or spiritual health
status.
• The resident is transferred to or returns from hospital.
ANC.0001.0009.0176
Information to be • The resident goes on social leave.

included into the • A new resident is admitted into the facility.
24 Hour Report
• A resident is administered a PRN psychotropic or analgesic medication.
cont.
iCare: For Care exceptions that need to be included in the handover report, leave the
“include in handover” box ticked. For entries that do not need to be included, untick the
“include in handover” box
Care Plan Ensure that the resident’s care plan has been updated if necessary and indicate in the
Up-Date “Care Plan Needs Updating” and “Care Plan is Updated” sections of the
24 Hour Report form (CF010).
iCare: For any care plan updates, an entry in the progress notes needs to be made by
the Clinical Leader or Registered Nurse to identify this
Subsequent Steps If an entry has been made into the 24 Hour Report you must:
• Ensure that the resident’s progress notes have been updated.
• Ensure that a Resident Incident form (CF005) has been completed if the care
“exception” has resulted from an incident.
• The “Actioned” Section of the 24 Hour Report form (CF010) must be completed
by the Clinical Leader, registered nurse or person in charge of shift and they
must sign the “Actioned” Box to acknowledge/indicate that the
issue/event/change has been actioned and resolved.
• All staff must read back in the 24 Hour Report form (CF010) for the past 48
hours.
• If an issue/event/change has not been actioned or resolved the Clinical Leader,
registered nurse or person in charge of the shift must re enter up-to-date
information into the 24 Hour Report form (CF010) regarding the status of this
issue/event/change.
For entries made in the iCare handover report you must:
• Ensure that the resident’s progress notes have been updated.
• Ensure that a Resident accident/Incident form has been completed if the care
“exception” has resulted from an incident.
• The Clinical Leader, registered nurse or person in charge of shift must update
the resident’s progress notes to acknowledge/indicate that the
issue/event/change has been actioned and resolved.
• All staff must read back in the iCare handover report for the past 48 hours.
• If an issue/event/change has not been actioned or resolved the Clinical Leader,
registered nurse or person in charge of the shift must re enter up-to-date
information into the progress notes regarding the status of this
issue/event/change.

ANC.0001.0009.0177
Section 7.07 Shift Handover Guidelines

Standard Handover of resident clinical and social information and care needs is essential to
ensure that relevant clinical and social information is effectively communicated from
shift to shift. The intent is that the resident receives a continuity of assessment, care
and relevant interventions over the following shift. It helps staff to plan their shift and
mobilise appropriate resources to provide the required care.
The Registered Nurse (RN) in-charge and the Clinical Leader (or delegate)are
responsible for ensuring a verbal and/or written/iCare handover is undertaken at the
changeover of shifts, in each cluster/RACF.
Handover Handover should include:

Inclusions
Resident care issues, for example:
• The names and location of residents who are unstable, unwell or palliating:
o What plans are in place to monitor their condition
o Escalation criteria that warrants further action
o Whether family are aware of the resident’s condition
• The names of residents:
Admitted to hospital, returned from hospital or on leave.
• New Admissions: Respite or Permanent.
• Any unresolved care concerns.
Facility and Equipment issues, for example:

• Any issues affecting normal operations of the facility.
• Any issues impacting the security of the facility and safety of the residents.
• Strategies in place to mitigate risk.
Staffing issues requiring management by the RN or Care Supervisor for example:

• Rosters coverage for each work unit.
• Staff absences are identified, where known.
• Replacement strategies for absences.
• Where efforts have been made to replace staff a list of staff already contacted
will be made available.
Resident or Family Concerns:

• Any concerns or complaints received during the shift are reported to staff on
the next shift to ensure appropriate follow-up of concerns.
• These concerns are to be escalated to the Clinical Leader and/or Manager if
deemed appropriate.
ANC.0001.0009.0178
Supporting Handover can be supported by the following procedures.

Procedures
Related ARV Procedures:
ARV has implemented the following procedures to support handover and ongoing care:
24 Hour Report 24 Hour Report or iCare Handover Report (CF010). The RN in-charge and the Clinical
and iCare Leader review the 24 hour report or iCare handover report at the commencement of
the shift, respond to the information held within and review the content from the
Handover Reports
previous 48 hours to ensure all identified tasks have been followed through. Care
planning for the shift and resource allocation is also considered as a result of this
process.
Significant Significant Episode Care Plans (7.05 Management of a Significant Episode Care Plan
Episode Care Procedure) are utilised to identify Residents who have a short-term change in their care
needs. This is also used to support handover and ongoing care for residents.
Plans
The RN in-charge and the Clinical Leader are responsible for the generation and review
of the SECP daily and signed off by the RN. The SECP folder is also reviewed at handover
to inform staff of residents who may have changes in their care needs and/or clinical
conditions.
The RN in-charge and the Clinical Leader are responsible for identifying any resident
who is being monitored for an acute change in their condition; waiting for a medical
review; waiting for medications to arrive and any other clinical condition which may
require RN review and/or monitoring. In the event of medical support not being
available and the RN has concerns regarding the clinical stability of the Resident the RN
must decide on the appropriateness of sending the resident to hospital for further
assessment and/or treatment. The usual procedures of consultation and
communication with the family/resident will be undertaken.
Transfer to If an ambulance is to be called for an unexpected transfer to hospital, as a result of

Hospital deterioration in clinical condition “000” must be called. The ARV Transfer to Hospital
Form (CF016) or iCare equivalent should be followed. The RN (or delegate) is required
to stay with the Resident whilst awaiting an ambulance transfer, if it is unexpected.
Medical For Medical Emergencies refer to 10.05 Management of a Medical Emergency

Emergencies Procedure.
Ambulance Non-Emergency Patient Transport and Electronic Booking System

Service
Non Emergency Patient Transport is provided by the Patient Transport Service which is
part of the Ambulance Service of New South Wales.
Non-Emergency Patient Transport is appropriate for patients who are going for day
treatment, being transported to an appointment (such as specialist or x-ray), return
from treatments or appointments and for patients being discharged from hospital
(either to their residence or to a lower acuity hospital).
ANC.0001.0009.0179
Ambulance To be eligible for Non Emergency Patient Transport, the patient will be medically
Service cont. unsuitable for public or private transport and will normally:
1. Require stretcher transport; or
2. Require observation by a Patient Transport Officer due to their medical
condition; or
3. Be a patient whose condition would cause the patient to be either gravely
embarrassed or unacceptable to other people in public transport
e.g. incontinence of bladder or bowel, gross deformity or disfigurement.
Non-Emergency Patient Transport is not for patients being admitted into hospital, or
patients that require cardiac monitoring, active clinical care or management of
intravenous fluids en route to hospital.
Ambulance provides inter-hospital transfers using the Patient Transport Service for low
acuity non-emergency patients or an emergency ambulance with a paramedic crew
when appropriate. Requests for Non Emergency Patient Transport undertaken by
Patient Transport Service can be submitted by Calling 131 233 or obtaining access to the
Electronic Booking System Overview.
Calling an The Emergency number in Australia is Triple Zero (000)

Ambulance • This is a free call from any phone, even a phone box or disconnected mobile
000 phone.
• When dialling Triple Zero (000) there is a short recorded message stating that
you have dialled the emergency number, then an operator will ask which
service you require - ambulance, police or fire.
• In the event of a medical emergency, ask for AMBULANCE.
• You will be connected to an ambulance control centre and asked a standard set
of questions by the operator. Answering these questions helps us get an
ambulance to you as quickly as possible.
• It is important to stay calm and speak slowly.
Once you have answered these questions the first available ambulance will be sent.
Additional questions will then be asked by the operator, who will also provide further
assistance or instructions depending on the situation.
Remain calm and do not hang up until the operator has obtained the required
information.
ANC.0001.0009.0180
Calling an Mobile Phones

Ambulance 000 • When possible contact Ambulance by calling Triple Zero (000) from a fixed
cont. phone.
• Mobile network capacity, topography, climate and even the number of users in
a particular location, can affect your ability to make a call in an emergency using
a mobile phone.
• If you have no alternative but to use a mobile phone dial Triple Zero (000) or
‘112' (contact can even be made if your mobile has been blocked or your
security settings have been activated).
• If you dial Triple Zero (000) but have no reception with your own mobile phone
carrier, dial ‘112' and your call will be carried by any available GSM network if it
is available.
It is always best to check with your mobile phone provider to see what number is best
suited for your model of mobile phone.
Ambulance does not have the capacity to receive an SMS text message from mobile
phones in an emergency.
All staff at ARV are required to undertake communication through the 7.08
Documentation Guidelines which articulates the documentation requirements from
admission to the end of the resident stay at ARV.
7.03 Care Planning/Assessments also support the on-going care needs of the resident
and responds to changes in care requirements. The care delivered should reflect the
identified needs in the care plan.
Specific These tools should be utilised as needed to inform an effective handover:

Handover
Specific Handover Requirements for the Castle Hill Roving ADON
Requirements
(Castle Hill Only) Registered Nurses (RNs) in charge of work units/clusters handover to the RN in-charge
of the evening shift.
The RN (or delegate) in-charge of the evening shift hands over the ADON on the night
shift.
The ADON on the night shift in turn hands over to the RNs in charge of units the next
day.
To facilitate the communication of key issues the evening RN is also required to send an
email summary of the evening’s events to the ADON on the night shift.
Ongoing concerns are similarly relayed, by email from the night ADON to the RN in
charge the following day.
Reference http://www.ambulance.nsw.gov.au/Calling-an-Ambulance.html

ANC.0001.0009.0181
Section 7.08 Documentation Guidelines

Standard Care related documentation will meet all relevant legislative and regulatory
requirements. Progress note documentation supports “exception documentation,
assessment and care planning and ACFI applications.
Rationale Clinical documentation comprises a system including assessments, care instructions &
care plans. These are resident focused multi disciplinary legal documents that reflect
the residents health, well being, care provided, the effect of care and the continuity of
care.
Documentation is a legal document that provides information that care has been
provided. It can be used to resolve questions or concerns about accountability and the
provision of care; it provides a chronological record of events.
Clinical • Must be completed in ink (not felt tip pen).

Documentation • Must be legible.
• Reports must be accurate and complete and include date and time of entry,
signature, designation and printed name. The 24 hour clock should be used.
• Incorrect entries must be lined through with a single line and initialled, do not
obliterate or make illegible.
• Each time initials are used the full name and signature must appear on the same
page.
• Documentation should be contemporaneous: This is documentation made into
a residents file at the time or as soon as practical after an event occurs or the
observation is made or the care given.
• Documentation should be an objective description as a result of direct
observation. Documentation must not be opinions or assumptions but rather
what was done, why it was done and the outcomes and resident responses.
• All entries should be clear, concise, comprehensive, current and factual.
• Should only include the use of ARV approved abbreviations.
Frequency of On entry 1-28 days:

Documentation • Documentation by all relevant staff be entered into the notes to help identify
care needs, support ACFI assessments and the development of care plans.
• After 28 days the Registered Nurses (RN’s) are to document a holistic and
comprehensive progress note identifying findings of assessments, interventions
and their effectiveness on all resident care needs. The progress note is to
include any other relevant resident related information and/ or additional
strategies used to meet the resident’s needs.
ANC.0001.0009.0182
Frequency of Ongoing:
Documentation • Exception Documentation
cont.
• High Care Residents – Weekly
• Low Care Residents – Monthly
ACFI Review:
• Documentation to support ACFI assessments and care planning.
Defining Care A care “exception” is defined as an action or event involving the resident that otherwise
“Exception” would be outside their “normal” day to day life or routine that staff on following shifts
should be made aware of. For example, a fall or episode of unusual behaviour would be
considered a care “exception”.
References Nursing and the Law Staunton & Whyburn
Potter & Perry’s Fundamentals of Nursing ed’n 2 2005
Online: Nursing Process & Critical Thinking Catherine Kuckty RN

ANC.0001.0009.0183
Section 7.09 Signature Register Procedure

Standard A Signature Register is maintained to meet regulatory requirements
Signature The Signature Register is a legal document that allows for the identification of staff
Register entries into care and related documents
The Signature Register details all staff:

Surname
Given Names
Signature
Initials
Signature Entry Each entry in the Signature Register must be witnessed by a person, who must detail
Witness their:
• Surname
• Given Names
• Signature
• Date.
Signing the When signing the Signature Register, the:

Entries • Staff member must only sign the document in the presence of the witness.
• Witness must only sign the document under the understanding that the staff
member signed the register in their presence.
• All entries must be dated.
Updating the The Signature Register must be updated when:

Register • Any new staff commence at the facility.
• Agency staff who have not previously attended and whose signature is not
currently recorded in the register.
Register Location The register is located at each RACF facility and is accessible to all staff.
The register is updated by Managers/Clinical Leaders.

ANC.0001.0009.0184
Section 7.10 iCare: Entering Information into ACFI Forms Instructional

Guide
Purpose To instruct on how to enter information into ACFI Forms & Charts to substantiate
correct ACFI claims.
What is included This guide includes:

in this guide? • Instructions on entering information into an ACFI Forms & Chart.
• Instructions on saving and exiting an iCare ACFI form.
Process
Enter Forms & From the Main Menu, click on the Resident Management button:
--
Charts
Resid ent Management
From Resident Management menu, click on the Forms & Charts button.
Forms & Charts ,'ii

From the Forms & Charts menu, click the Enter Forms & Charts button.
Enter Forms & Charts a
ANC.0001.0009.0185
Select the Upon clicking Enter Forms & Charts the screen will change to provide the user with the
Resident and the opportunity to enter any Charting & Observations, any Assessment Tools & Forms or
any ACFI Forms.
Appropriate ACFI
Form In the example below a single resident is selected and the Urinary Continence Form has
been selected from the list of available forms in ACFI Forms.
Once the appropriate form has been selected, click the Submit button.
Enter Form s
* Facility ARV Head Office
I/':) Al l res idents assigned to me

IE) Select Location
@ Select Resident( s)
* Resident( s) Select Resident

ADAMS, Dra y [El
ALBERTA, Blue
AMIE. John
APPS, joe
ARNOLD, John
BEAN, Roslyn
I/':) Charting & Observations

* Form Type IE) Assessment Tools & Forms
@ ACF! Forms
Urinary Continence Form
Select the Once the Submit button has been clicked a new window will open up displaying the
Resident/s and selected resident and requiring the selection of an ACFI start date.
the Pain Chart
Once the appropriate start date has been selected, click Create.
cont.
Urin ary Cont inen ce Assessm ent
Residency det ails

Name/ ID : Albe rt FLOO D
!Fac ility: ARV Hea d Offi ce ( 100 1)
(URN: 56789010)
ACFI a ppraiser ident ification det ails

Appraiser: !Profess ion:
Signature: !Da t e:
Pl ease se lect th e assess ment sta rt date:
lih@I FMIH 1
ANC.0001.0009.0186
Enter Information Once the necessary information has been entered into the ACFI assessment form, type
and Save and your password and click Save and Close.
Close an ACFI
When an ACFI form is saved and closed it provides facility managers and ACFI co-
Assessment ordinators the opportunity to review the information and if necessary make
amendments.
Note: Do not click complete as changes cannot be made to completed ACFI forms.
Urinary Continence Assessment
Residency details
Name/ lD: A lbert FLOOD / 45512 3 4
Facility: ARV Head Office ( 100 1)
(U RN : 567890 10 )
ACFI a raiser identification d etails

Appra iser: Profession:
Signature: Date:
Hour startina @ 19- Ju n - 2011 20 - Jun - 2011 21- Jun- 2011

0000
0100
0200 3 1
0300
0400
0500 4 2
0600
0700
0800
0900 2 2
1000
1100
1 200
1300
1400 2
1500 3
1600
1700 2
1800
1900 2
2000
2100
2200
2300
# of eoisodes 4 3 3
0
Continen ce Codes
Click "Save and Close". DO NOT
1. Incontinent of urine CLICK comp l ete.
2. Pad change for incontinence of urine
3. Pad has increased wetness
i-i\lfl:hii+J•;11111111
4. Passed urine during scheduled toileting
Password:
Enter Information After you have clicked Save and Close a new window will open informing you that as the
and Save and form is incomplete and the data in the form cannot be viewed in the ACFI appraisal.
Close an ACFI
Click OK
Assessment
cont. Messag:e from webpag:e ________ GiJ ~
Th,is form is cummtly urifi n ish ed a nd d ata w ill not b e v ie.w£d in ACF!
App rais.al.
Th,e form details w ill b e sa'/ed to t h,e re5id ent'5 ·fi le,
Do, you v.ish to <:0ntin1.1 e_
fi_ o_
K TII Ci!tncel j
References Aged Care Funding Instrument (ACFI) Assessment Pack, Australian Government –
Department of Health and Ageing, July 2007.

ANC.0001.0009.0187
Section 7.11 iCare: Completing ACFI Forms and Charts Instructional

Guide
Purpose To ensure that all information is correct prior to the completion of ACFI Forms and charts by
ACFI coordiators or persons with ACFI delegated authority.
What is included This guide includes:

in this guide? • How authorised staff find and review saved iCare ACFI Forms & Charts.
• How authorised staff find, review and complete saved iCare ACFI Forms & Charts.
Process: Reviewing and Completing Saved ACFI Forms & Charts
Finding and From the Main Menu, click on the Resident Management button:
Reviewing Saved - --
ACFI Forms & Re5ident Management
Charts
- ,
Forms & Charts
From the Forms & Charts menu, click the View Forms & Charts button.
- .
View Form5 & Charts
Search for an Upon clicking View Forms & Charts the screen will change to provide the user with the
Unfinished or opportunity to enter any Charting & Observations, any Assessment Tools & Forms or
any ACFI Forms.
Completed ACFI
Forms & Charts In the example on the next page a search will be performed for a single resident’s
Urininary Continence ACFI Form saved or completed in the last 22 days.
ANC.0001.0009.0188
Search for an Once the appropriate information has been entered click Submit.
Unfinished or v1e,v Fonns
Completed ACFI * Facility AAV Head ~ce·
Forms & Charts 0 A ll r@si d@nts ..issign@d to m@
cont. '.) Sslecl!: l..ocatio:n
1~ Sel!ect Resident{s)
Selecl Re!iiident
ADAMS, Dray
.Al.BERTA Blu~
AMIE , Jo!hn
APP S. Joe
ARNOLD, John
BEAN, IR.cislyn
D Chartingr& Obs;ervations.
A ssessment Tools & F1orms
* Form Ty,pe
l!) AC l Forms
A ll A ssessment & AOFI Fo rms
Urinary Continenc,e Form

From 1/061.201 1
To 121J0E/2O11
Search Results The results screen when searching for ACFI Forms allows the user to filter by All Forms,
Completed Forms and Unfinished Forms.
The form itself can be viewed by clicking on the form link. This allows you to view a
completed form to complete an unfinished form.
In the example below the resident’s unfinished Urinary Continence Form has been
retrieved.
Forms & Charts
Search results ' - •_•_•_•_•_•_•_•_•_•_•~•~...

Active Forms Filter by Completed and
Unfinished Forms.
Vi ew as list
.. ,. . . , ; ,. .
Albert FLOOO Alex Thompson Unfinish ed 23/ 06/20 11 4 :49 : 11 PM
Click on the form link
to view the form
0 Back to Mam 0 Back to Sub-Menu 0 Form Data Search
The Archive component displayed on this screen will be discussed further in this Quick
Reference Guide.
ANC.0001.0009.0189
Open the Once the form link has been clicked a new window will open displaying the completed
Unfinished or or unfinished form. In the example below the unfinished Urinary Continence Form is
displayed.
Completed ACFI
Forms & Charts Once the data is reviewed and any additional information added type your password
and click Complete.
Notes:
• Unfinished forms can have additional data added to the form.
• Completed forms can only be viewed
Urinary Continence Assessment
Residency details
Name/ ID : Albert FLOOD / 456 1234
Facili ty: ARV Head Office ( 1001)
( URN : 56789010 )
ACFI appraiser identification details

Appraiser : Profession :
Signature : Date :
Hour startinq @ 19-Jun-2011 20-Jun-2011 21-Jun-2011

0000
0100
0200 3 1
0300
0400
0500 4 2
0600
0700
0800
0900 2 2
1000
1100
1200
1300
1400 2
1500 3
1600
1700 2
1800
1900 2
2000
2100
2200
2300
# of eoisodes 4 3 3
Continence Codes
1. Incontinent of urine
2. Pad change for incontinence of urine
3. Pad has in creased w etness
4. Passed urine during scheduled toileting
Click " complete" to complete the form
and make the data available for ACF I
Password: WfM¥iHS1+1M [IM@I] calculations.
After you have clicked Complete a new window will open informing you that as the
form will be saved in the resident’s file and can be viewed as part of an ACFI Appraisal.
Click OK.
Message from webpage
This form will now be saved to the resident's file and may be viewed in
ACR Appraisal.
Do you wish t o continue?
[1 OK ] ~[__
ca_n_c_el_~
ANC.0001.0009.0190
Archiving / The results screen when searching for ACFI Forms allows the user to filter by All Forms,
Deleting a Completed Forms and Unfinished Forms. This screen also allows users with a Facility
administration user role to Archive completed or unfinished ACFI forms.
Completed ACFI
Forms & Charts To Archive a completed or unfinished ACFI form, select the Archive checkbox next to
the form that is to be archived and click the Archive button.
In the example below the resident’s unfinished Urinary Continence Form has been
retrieved and the Achive selection check box has been selected.
Forms & Charts
T-
Search results
Act ive Forms All Fo rms
View as li st
.. ,. • ' I : I , ,
A lbe rt FLOOD Urinary Continence Form A lex Thompson Completed 23/ 06/2011 5: 4 6:03 PM
To archiv e a form ensure the

archive check box is t icked and
then click Archive.
0 Back t o Mam 0 Bac k to Sub-Menu 0 For-m Data Search
Once the Archive button has been clicked a new window will be displayed detailing the
iCare components that will be impacted when the form is archived. ACFI forms are
linked to the ACFI iCare wizard to provide information for ACFI claims.
As the data is not required for ACFI claims ensure the RCS/ACFI Wizard check box has
been ticked. Once the RCS/ACFI check box has been ticked, click Submit.
Form Archive To ensure the form data is not

available in ACFI caluclations, ensure
You are about to archive the below forms that the RCS/ACF I check box is ticked
Detail of forms selected for arch1Ve Would you like the details of the selected forms to be permanently de leted from:
Resident Name Form Entered By Date Progress Notes Care Plan Wizard* RCS/ ACFI Wizard Mngt Reporting Data
Urin a ry Continence
Alb ert FLOOD T hompson , Al ex 23 Jun 11, 16: 3 1 No Current Links No Current Links No C u rr e n t Links
Fo r m
*Care Pl a n Wi zard - th is v.ri l l not ch ange t h e r esi dent's ex ist ing care p la ns
After you have clicked Submit a new window will open confirming that you wish to
Archive the form selected in the previous screen. To Archive the form, click OK.
Mes!iagefrom webp age
,c: y,ou surt you w ant to ~rchivc: tht stlt cttd 1:omplcttd for m(5)?
n OK TI~
[ _ Ci_nc:_
,EI~
Once you have clicked OK you will be returned to the Forms & Charts search results
screen where you will see the form you have just archived has been removed from the
search results.
ANC.0001.0009.0191
Begin a New ACFI From the Main Menu, click on the Resident Management button:
Form or Chart for -
the Resident Resid ent Management
- Forms & Charts -a

From the Forms & Charts menu, click the Enter Forms & Charts button.
Enter Forms & Charts a -
Upon clicking Enter Forms & Charts the screen will change to provide the user with the
opportunity to enter any Charting & Observations, any Assessment Tools & Forms or
any ACFI Forms.
In this example a single resident is selected and the Urinary Continence Form has been
selected from the list of available forms in ACFI Forms.
Once the appropriate form has been selected, click the Submit button.
Enter Forms
* Fa cility ARV He ad Office T
0 All residents assigned to me

0 Select Lo cation
@ Select Resident( s)
* Resident{ s) Select Resident A
ADAMS , Dray [;;;]

ALBERTA, Blue
AMI E, John
APPS , j oe
ARNOLD, John
BEAN , Roslyn
0 Charting & Observations

* Fo rm T ype 0 Assessment Tools & Form s
@ ACF! Forms
Urinary Continence Form
iiti@M
ANC.0001.0009.0192
Select the It is important to note that assessments can be initiated for a resident up to three
Assessment months prior to the current date (Today).
Start Date
Once the correct date has been selected, click Create to begin a new assessment for the
selected resident.
Urin ary Continence Assessment
Residen det ails

Name/ JD: Alb ert FLOOD
Faci lity : ARV Head Office ( 1001)
(URN: 56789010)
ACFI a ppra iser iden t ific at ion d etails

Appra iser: Pro f essio n :
Signature: Da te:
Please select t he assess ment s tart dat e:
19✓ un~201 1 I
IMIM@M
References Aged Care Funding Instrument (ACFI) Assessment Pack, Australian Government –
Department of Health and Ageing, July 2007.


Anc 0001 0009 0151

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ANC.0001.0009.

Module VII – Assessment, Care Planning and Documentation

Assessment, Care Planning

Section 7.01 Assessment, Care Planning and Documentation Policy

The Clinical Leader is responsible for identifying an appropriate delegate to

Governance Professional documentation will:

Nursing documentation provides accountability in record keeping describing the

Reviewed: Internal Reference Group, 21/12/2011

Section 7.02 Assessment and Care Planning Procedure

Standard Care delivered in residential settings is based on assessment and individual

Responsibilities The Registered Nurse is responsible for:

Care staff are responsible for:

Care Plan The Clinical Leader is responsible for:

Staff responsible for writing the care plans are to:

Review and Definition:

Care plans must be evaluated when an ACFI is re appraised.

ACFI The Facility Manager/Clinical Leader is responsible for:

ACFI ACFI Appraisal and Assessment Pack

Reviewed: Internal Reference Group, 21/12/2011

Section 7.03 Guidelines for Completing Assessments and Care Plans

The Cognition Assessment consists of:

Sleep Assessment consists of:

Communication Assessment consists of:

The Hygiene Assessment consists of:

Scope cont. Nutrition Assessment consists of:

Pain Assessment consists of:

Skin Assessment consists of:

Toileting and Continence Assessment consists of:

The Medication Assessment consists of:

Oral and Dental Assessment consists of:

Scope cont. Falls Assessment consist of:

Diversional Therapy Assessment (completed by Diversional Therapists) consist of:

Source Relevant assessment information may also be obtained from:

Red Tab – Cognition assessment, care plans and tools.

ACFI Pack ACFI Pack Documents

Reviewed: Internal Reference Group, 21/12/2011

ACFI, Admission, Assessment, Care Plan, Documentation and Review Process

ACFI Pack Assessments Progress Notes

Sign ificant Episode Care

• ACFI compu lsory Family/Resident

Manual: Managing Ca re & lifestyle Copyright ARV June 2012 Page 11 of 42

Care Administration & Care Correspondence When to be ACFI PACK Responsibility

Care Conference Notification (CF024) When Required - RN

iCare Checklist for Admission for New Resident Compulsory - RN

Respite Confirmation Letter (CF060 and CF060A) When Required - RN

Resident Consent Form (CF027) Compulsory - RN

Resident Details Form (CF026) Compulsory - Admin / RN

Resident Entry Status (CF021) Compulsory - RN

Resident Transfer Form (CF016) When Required - RN / Person –

Cognitive, Behaviour and Restraint Management

Bed Rail Assessment Form (CF049) When Required - RN

Cognition Reference Tools (CF105B) When Required -

Cornell (CF 101) When Required Compulsory RN

PAS (CF100) When Required Compulsory RN

Restraint Application and Release Log (CF014) When Required - RN

Restraint Authorisation (CF014) When Required - RN

Resident Identification Form (CF015) When Required - RN

Wandering Behaviour Assessment /Care Plan (CF105C) When Required - RN

Cognitive, Behaviour and Restraint Management cont.

Behaviour Record for Wandering (ACFI 7) When Required Compulsory RN

Behaviour Record For Verbal Behaviour (ACFI 8) When Required Compulsory RN

Behaviour Record for Physical Behaviour (ACFI 9) When Required Compulsory RN

iCare Behaviour Chart When required - RN