Under the SIRS, all incidents that happen in your service must be effectively recorded and managed in your service’s Incident Management System (IMS). This includes near misses.
Records should be thorough, include all relevant details, and be easily understood by others.
A full incident record on your IMS provides transparency and a complete picture for the Commission and your service. It is critical to ensure this data is captured and can be analysed to meet legal requirements, and reduce future risks and drives continuous improvement. A thorough record provides the details required when the Commission needs to be notified of a reportable incident.
When creating, updating and maintaining records on your IMS, it is important you include:
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a detailed description of the incident
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who was involved and impacted
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what consultation occurred
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what actions and notifications occurred
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any implementations of solutions
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any background information or other events that contributed to the incident.
Under the SIRS, all incidents that happen when delivering or coordinating a service or are witnessed or suspected must be recorded and managed in your Incident Management System (IMS). This includes near misses.
Records should be thorough, timely, and include all relevant details so they can be easily understood by others.
A full incident record on your IMS gives a complete picture for the Commission and your service. It is critical to ensure this data is captured and can be analysed to meet legal requirements, and also reduce future risks and drive continuous improvement.
When creating, updating and maintaining records on your IMS, it is important you include:
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a detailed description of the incident or allegation
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who was involved and impacted
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what investigation and analysis has taken place
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what actions and notifications have happened
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any implementations of solutions
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any background information or other events that have contributed to the incident.
Tip
After the incident has been recorded in your service's IMS, ask yourself:
‘Can this record be understood by someone who was not there?’
Key actions
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Make sure workers in your service understand the importance of recording incidents and its relationship to preventing incidents and continuous improvement
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Ensure your policies and procedures clearly outline the details required for recording incidents in your IMS
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Keep all records for 7 years after the incident was identified
Key actions
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Learn the importance of recording incidents and how it can help prevent future incidents
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Learn your services' policies and procedures so you know what to include and the level of detail required when recording incidents into your IMS
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Know how to identify and report patterns of abuse
Key actions
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Learn the importance of recording incidents and how it can help prevent future incidents
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Learn your service’s policies and procedures so you know what to include and the level of detail required when recording incidents into your IMS
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Know how to identify and report patterns of abuse
Your role
It is important to understand your role in record keeping as a manager of your service so you can set clear expectations and policies. This ensures your workers know what to do when an incident occurs.
You can influence the quality of record keeping by:
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delivering ongoing education and training to ensure workers know how to report incidents and near misses
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providing work examples of good record keeping
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recording incidents even when they are discovered after the fact or where they have already been resolved.
Your role
It is important to understand your role in record keeping as a worker. Look at your service’s policies and processes used for your IMS. Who should you report to, and how?
You can influence the quality of record keeping by:
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engaging in training to learn how to report incidents and near misses
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following guidelines laid out by management for good record keeping
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recording incidents even when they are discovered after the fact or have already been resolved.
Understand what to include in incident records
Your service’s policies should clearly outline what details need to be captured when recording an incident into your IMS. Do your workers know what they need to include in a record? Your policies, training, and systems can prepare workers to react appropriately to incidents and understand what information they need to collect.
When entering incidents or reviewing worker entries on the IMS, ask yourself the Who, What, Where, When and How questions about the incident.
Understand what to include in incident records
You need to know what details are required when recording an entry in your IMS. Become familiar with your service’s policies, training, and systems for recording incidents. Ask management about how to act when an incident happens and what information you need to collect.
When entering incidents on the IMS, ask yourself the Who, What, Where, When and How questions about the incident.
Who, what, where when and how helps you to know what information you and your workers need to gather. These questions tie into the seven key subjects that should be covered in an incident record.
These key subjects should provide in-depth details on the incident and any changes made after the incident.
Who, what, where, when and how is the beginning of what information you need to gather. These questions tie into seven key subjects that should be covered in an incident record.
These key subjects should provide in-depth details on the incident and any changes made after the incident.
Work tool
You can use the Understanding key details work tool to know what to include in each incident record. This work tool expands on the seven key subjects.
Tip
Ask yourself
Consider the following items when recording an incident:
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can the record be understood by someone who was not there?
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what is the level of cognitive impairment of the consumers directly involved in the incident?
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have the people involved in the incident been interviewed? Clinical notes often do not give a thorough record on their own.
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clinical observations and their meaning may be relevant for the incident record.
Remember, a detailed incident record can be used to prevent future incidents and ensure the safety and wellbeing of everyone involved.
Tip
Ask yourself
Consider the following items when recording an incident:
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do the consumers involved in the reportable incident have any cognitive impairments?
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have the people involved in the incident been interviewed? Clinical notes often do not give a thorough record on their own.
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clinical observations and their meaning may be relevant for the incident record.
Remember, a detailed incident record can be used to prevent future incidents and ensure the safety and wellbeing of everyone involved.
Incident patterns
Some incidents may appear to be minor in isolation, however the level of harm can increase if they occur repeatedly.
Minor incidents should be recorded in your IMS to help recognise and report incident patterns. A pattern of abuse can be recognised with thorough recording of incidents and resolved by the service to prevent it from continuing.
Incident patterns
Some incidents may appear to be minor in isolation; however, the level of harm can increase if they occur repeatedly.
Minor incidents should be recorded in your IMS to help recognise and report incident patterns. A pattern of abuse can be recognised with thorough recording of incidents and resolved by the service to prevent it from continuing.
Privacy and confidentiality
You must maintain consumer privacy and the confidentiality of records in your IMS, particularly where it relates to individual consumers. Personal and sensitive information must be securely stored. When information needs to be shared within the service or with other parties such as the Commission or police, privacy and confidentiality must be maintained.
Updating incident records
Make sure you update incident records as more information becomes available and as you implement actions when responding to an incident. An incident record can be different on the day it is reported compared to a week later when changes have been implemented.
Retaining incident records
All incident records must be retained for 7 years after the incident was identified. You should have appropriate controls to maintain the privacy and confidentiality of all incident information, particularly where it relates to consumers' sensitive and personal information. Records relating to incidents (for example, correspondence regarding incidents) should be kept together with your incident records.
Incident records must be kept for 7 years after the incident was identified.
Contact us
If you have a question about the SIRS, you can call us on 1800 081 549. This phone line is open 9 am to 5 pm (AEST) Monday to Friday and 8 am to 6 pm (AEST) Saturday to Sunday.
You can also email us at sirs@agedcarequality.gov.au.
Facilitated workshops
The Commission provides facilitated workshops to sector participants. All current workshops are available on the Commission’s Workshop page.
Online learning
The Commission’s Aged Care Learning Information Solution, Alis provides free online education for employees of Commonwealth-funded aged care providers, including modules covering reportable incidents and the eight reportable incident types.
You can access Alis at learning.agedcarequality.gov.au.
Disclaimer
The information contained on this page is intended to provide you with general guidance; however, it is your responsibility to be aware of your legislative requirements.
