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6.1
6.2
6.3

DOCUMENTATION POLICY

06 It is an NDIS requirement that a support worker/coordinator writes case notes after completing every shift. It is best practice that the employee/sub-contractor completes case notes towards the end of their shifts in situations where this is not possible, employees/sub-contractors are required to complete case notes within 24 hours of the completion of their shift.

Case notes are to be logged in the company’s app [Lookout/Care view]. If in a situation where the app is not working, notify Decent Care as soon as possible. The employees/sub-contractors are required to log into their timesheet via the DC QR app in such circumstances.

6.1 CASE NOTES QUALITY & REQUIREMENT

Decent Care employees/sub-contractors are provided with a decent care folder that outlines the quality and standards of the case notes. Employees/subcontractors can reflect on the documentation in the DC folder for writing their case notes.

The case notes should outline the following,

  • How the support worker/coordinator has provided service that helps the participant achieve their goals.
  • Writing sentences in “active voice” is recommended as opposed to ‘passive voice”, in order to emphasise the order of the tasks recorded.
  • The case notes should contain factual information.
  • The notes must be specific and informative but also succinct and clear.
  • Progress notes must include both positive as well as negative developments and be written impartially, including any errors made by the carers.
  • Case notes should include the hours worked.
  • The signature of the participant is required after completing the case notes in the DC QR app for the participants to acknowledge the KM's travelled are true and accurate. [Support Workers].

To ensure the highest quality and standards the case notes are monitored by Decent Care every week.

6.2 NON-COMPLIANCE

  • Quality & Standards

If the quality of the case notes does not meet the standard, Decent Care will send an email to the employee/sub-contractor outlining the areas of improvement. Further training can also be provided upon request or if Decent Care deems it necessary to do so.

If the quality of the case note does not meet the Decent Care standard even after outlining the areas of improvement or training. Decent Care will send a warning in writing via email.

If the quality of the case notes does not meet the Decent Care standard after the warning. Decent Care will temporarily suspend shifts until the conditions are met.

  • Missing case notes

If an employee/sub-contractors fails to complete their case notes. Decent Care will send a warning in writing via email. If the employee fails to comply with the warning and fails to complete the case notes, Decent Care will temporarily suspend the shifts until a written explanation is provided by the employee/sub-contractor

Employees/sub-contractors may face disciplinary action for not completing the forms. Decent Care team leaders are responsible for assessing if an employee has failed to complete a form when it was required to. In such situations, the employee/sub-contractor will be required to undergo training. If the employee/sub-contractor still fails to complete the forms after undergoing training provided by Decent Care, in such circumstances, there might be a temporary suspension in employment/contract until the matter has been resolved.

6.3 FORMS & PROCEDURE

It is an NDIS requirement that incidents, hazards, goals, financial transactions, conflicts of interest, and complaints are to be documented.

Decent Care provides all its employees/sub-contractors with a folder and a QR code app that enables the employees to document all of the above via a form.

It is the responsibility of the employees/sub-contractors to fill in the forms with utmost urgency when required.