What are the standards of documentation in geriatric care in Australia?

From the Guidelines

Standards of documentation in geriatric care in Australia are guided by reputable organizations such as the Australian Commission on Safety and Quality in Health Care (ACSQHC) and The Royal Australian College of General Practitioners (RACGP).

Key Principles

• The ACSQHC has developed guidelines with a high quality score of 81.9% according to the Appraisal of Guidelines for Research & Evaluation–II (AGREE-II) instrument 1
• These guidelines emphasize the importance of clear and accurate documentation in geriatric care, including medication management and fall prevention strategies
• The RACGP also provides guidelines for geriatric care, although with a slightly lower quality score of 69.7% according to AGREE-II 1

Best Practices

• Documentation should be tailored to the individual needs and priorities of older adults, taking into account their medical history, medications, and functional abilities
• Healthcare providers should use standardized assessment tools and quality indicators to inform their documentation and care planning
• Effective partnerships between healthcare providers, aged care homes, and organizations are crucial for generating and translating high-quality evidence into practice 1
• Strategies for translating evidence into practice include education and training, audit and feedback, and engagement with internal and external stakeholders 1

From the Research

Standards of Documentation in Geriatric Care

The standards of documentation in geriatric care in Australia are multifaceted and influenced by various factors. Some key aspects include:

• Advance care planning (ACP) documentation prevalence, which was found to be 46.5% in a study of older Australians accessing health and aged care services 2
• The quality of advance care directives (ACDs), with only 73% of ACDs including full name, signature, document date, and witnessing 2
• The use of person-centred care models, such as the one proposed for residential aged care, which prioritizes dignity of risk and quality of life 3

Documentation Quality and Assessment

The quality of documentation in aged care can be assessed using instruments such as the Quality of Australian Nursing Documentation in Aged Care (QANDAC) instrument, which measures the quality of paper-based and electronic resident records 4. Additionally, studies have investigated aged-care nurses' knowledge of nursing documentation, finding that they have considerable knowledge but may benefit from comprehensive education programs 5.

Factors Impacting Documentation Quality

Research has identified several factors that impact clinical data and documentation quality in Australian aged care and disability services, including:

• Staff-related challenges
• Education and training
• External barriers
• Operational guidelines and procedures
• Organisational practices and culture
• Technological infrastructure
• Systems design limitations
• Systems configuration-related challenges 6 These factors highlight the complexity of ensuring high-quality documentation in geriatric care and the need for coordinated efforts to address these challenges.