Introduction to Aged Care Assessment Program Self-Directed Learning Package - Generic Section - Version 4.0
Record keeping and Data Management
Up to Aged Care Assessment Teams
The ACCR
The Aged Care Client Record (ACCR) is the formal client record, application and approval form. The Act prescribes the use of the ACCR. It is not a client assessment form or tool, although it does record some assessment data and provide essential narrative data to inform the service provider of care needs.The Interim ACCR User Guide 2007 has been designed as a user friendly guide for those who use the Aged Care Client Record (ACCR). It is anticipated that both assessors and administrative staff will use the booklet in their everyday practice to guide and inform them about Minimum Data Set,Version 2.0 (MDS V2.0) data items, definitions and codes, rather than the more comprehensive, but more technical, ACAP Data Dictionary, Version 1.0 (AIHW, 2002).
Changes to the ACCR have been made in 2007 and the new form is available.
The ACCR contains the following parts:
- a statement of application
- Part 1 for registration of client information
- Part 2 to record information about intervention and contact dates
- Part 3 to collect information about the clients' carers, where they exist
- Part 4 to record information on the clients' activity limitations and assistance required
- Part 5 is an assessment summary and information for service providers
- Part 6 is the care recipient approval.
eACCR
The Department of Health and Ageing, in conjunction with Medicare Australia, are introducing an electronic method of submitting the Aged Care Client Record (ACCR) to Medicare for payment.During 2008 this project will be in a demonstration phase and ACATs in New South Wales, Victoria, ACT and Western Australia have agreed to participate. The remaining states and territory are being consulted about their involvement. Following evaluation of the demonstrations, consideration will be given to a national rollout.
It is expected that the eACCR will ultimately reduce the amount of paperwork required to implement approvals as Providers will be able to access the eACCR via Medicare's on-line Claiming website. Consequently, they will not require a paper copy of the client's ACCR.
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ACAP Minimum Data Set
A national Minimum Data Set (MDS) for the Aged Care Assessment Program has been developed to promote consistency of data collection and to:- provide access to data for policy and program development, strategic planning and performance monitoring against agreed outcomes
- facilitate improved internal management and local/regional area planning and coordinated service delivery
- facilitate consistency and comparability of ACAP data with other relevant information in the health and community services field.
All parts of the ACCR must be completed for those clients who apply for residential care, respite care, Community Aged Care Packages (CACPs), and flexible care (Extended Aged Care at Home, Transition Care Program etc). Those clients assessed but not approved for any of the above should also be entered on the MDS. The key criterion is acceptance for a comprehensive assessment, irrespective of whether the assessment is completed.20
The MDS comprises the data collected from parts 1 to 4 and 6 of the ACCR. Part 5 is designed to complete an assessment summary and information for Service Providers. At this time it is not part of the MDS data collection.
MDS V2.0 does not record all ACAT activity or all client contacts. Clients excluded from MDS V2.0 are those not accepted for a comprehensive assessment and include:
- people seeking ad hoc advice or information from an ACAT who do not require a comprehensive assessment of their care needs
- medical consultations that do not incorporate the physical, psychological, cultural and social aspects of comprehensive assessment, e.g. referrals from one ACAT member to another of a different discipline
- discipline-specific assessments (e.g. an OT assessment that is not part of a comprehensive assessment).
All staff in an ACAT are likely to play some part in either entering MDS data or completing an ACCR, therefore all staff must familiarise themselves with the ACCR User Guide and continue to refer to this document to ensure high quality data entry.
MDS data is submitted quarterly to your evaluation unit where it undergoes data quality checks. Any data errors or anomalies are returned for correction. Having to recall old client records can be a painstaking process, it is therefore good practice to ensure the data entered first time is 100% correct.
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Activity 9
What software program does your team use to capture MDS data? What is your role in entering MDS data? What steps does your team take to ensure all data is accurate?Notes:
Medical terminology and coding
Completing the ACCR and MDS requires the client's medical condition to be coded according the ACAP Data Dictionary V1.0 – an abridged version of common diagnoses and codes is included in the ACCR Users Guide.Correct coding requires an accurate description of the client's condition. It is not uncommon for a client's condition to be different to the available codes. It is a clinical responsibility to ensure the description and codes used are accurate. It is therefore important that all ACAT members completing an ACCR have ready access to the Data Dictionary to ensure their terms are consistent with the codes. The codes are reviewed from time to time to remain current.
Activity 10
Review the two case studies at Appendix 4. Complete an ACCR for each client based on the information provided in Part 1.Notes:
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Privacy and confidentiality issues
ACATs must respect the privacy of client information at all times. Both state or territory and Commonwealth Government privacy laws must be adhered to. Where information needs to be disclosed to third parties, the client must have signed the ACCR application form. This should be recorded in the clients file.To assist in maintaining privacy and confidentiality ACATs are reminded to:
- be aware of their surroundings when conducting assessments or client focussed discussions. Ensure others cannot inadvertently overhear
- not leave client records or details (including diaries) in cars or on desks. Ensure they are secured at all times
- not leave client detail on phone messages, faxes or emails unless the recipient is known and the information is secure
- not discuss client details with informal contacts e.g. health professionals not involved in the clients care, friend, relatives
- ensure any data collection system used or developed comply with necessary privacy requirements.
Record keeping
ACATs are required to keep sufficient documentation to be able to support their decisions. In addition most ACATs keep client records as part of their auspice organisation and therefore are required to abide by local policy on record keeping.Record keeping is important for two reasons, the client record:
- is a legal document
- is the main means by which client information is able to be communicated among team members. Any team member should be able to look in the record and access all information necessary to take over responsibility for a client or assist the client in times of absence of other team members.
- consent form (separate to the ACCR)
- assessment tools
- notes detailing the outcomes of discussions with the client, carer or service provider
- copies of referrals.
Reporting requirements
Given the time it takes to check data quality and to assimilate reports from all teams at the state/territory level it is important that teams meet their reporting deadlines in order for the EU's to meet their time frames. This will assist in ensuring the quarterly and annual reports are able to be released in a timely manner. Your manager will implement a reporting timetable in order that your team's data is ready for them to meet their reporting requirements.Activity 11
Managers and administrative staff activity: What are your reporting timelines to the EU, state/territory and your local auspice?Notes:
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