Put in place an information management system* to manage records.

Put in place a system* for managing information, including the clinical information system* (Outcome 5.1), that:

• gives workers and others such as visiting health professionals, agency workers and contractors access to the right information at the right time
• enables older people to access the information they need to receive quality care* and services
• makes sure stored information is accurate and complete. This also applies to information that’s shared between services that provide support to the older person such as telehealth* services.
• makes sure that you get informed consent* (Outcome 1.3) to collect, use and store older people’s information. You also need informed consent* to disclose older people’s information with other people or organisations. This includes assessment information. If an older person withdraws their consent, record and communicate this.
• integrates information from different sources where needed, such as information from hospitals.
• manages cyber security risks (Outcome 2.4)
• has enough data storage for the records you need to keep.

The information management system*, including the clinical information system*, should be digital where possible. This will be specific to each provider*. There should always be ways to access critical information when digital systems are offline. For example, you can:

• put in place processes to make information available offline
• put in place processes to record clinical information on paper during internet or power outages.

Use your information management system* to record information.

Use the information management system* to make sure you securely manage any records at the service. Use the information management system* during processes*, systems* and strategies to do with:

• choice, independence and quality of life* (Outcome 1.3) and transparency and agreements (Outcome 1.4). Make sure information about the older person’s care, services, and agreements and care commencing (whichever comes first) is:
  • is current, accurate, timely* and easy to understand
  • supports the older person to make informed decisions
  • is accessible by workers
  • helps workers to partner with older people to make informed decisions based on accurate and timely* information.
• human resource management (Outcome 2.9). Store information from possible candidates and existing workers accurately against their profile.
• assessment and planning (Outcome 3.1). Each older person’s care and services plan* needs to include information about the risks associated with the delivery of care and services. It also needs to include how workers can support older people to manage these risks (Outcome 2.4). Make sure you securely store information from assessment and planning and risks and use it to inform the systems* for:
  • comprehensive care* (Outcome 5.4)
  • safe and quality use of medicines (Outcome 5.3) and antimicrobial stewardship* (Outcome 5.2)
  • clinical safety (Outcome 5.5)
  • infection prevention and control in the environment (Outcome 4.2) and when you deliver clinical care (Outcome 5.2)
  • palliative care* and end-of-life care* (Outcome 5.7)
  • food, drink and the dining experience* (Outcomes 6.1, 6.2 and 6.4).

Put in place a clinical information system*. This should be digital if possible. Use it to record and manage older people’s clinical information. For example, transitions of care (Outcome 3.4), assessment and planning (Outcome 3.1) and medication management* (Outcome 5.3). This will help you to deliver safe and quality care* and services. Where possible, the clinical information system* should also record Quality Indicator data. The guidance for Outcome 5.1 has more information on the clinical governance* framework.

Workers need to monitor and record each older person’s preferences, function and changes during activities of daily living*. For residential care providers, the guidance for Outcome 7.1 has more information on supporting older people with activities of daily living*.

During transitions of care*, make sure you give the family, carers, health professionals* or organisations that are involved the older person’s care timely*, current and accurate information about them. Make sure you provide this information with the older person’s informed consent*. The guidance for Outcome 3.4 has more information on coordinating care and services. For residential care home providers, the guidance for Outcome 7.2 has more information on transitions.

For home care providers, information about the older person’s care, such as nutritional needs or activities of daily living*, can be stored in the clinical sections of your database. This doesn’t need to be a dedicated clinical information system*. Make sure information about a person’s safe delivery of care and services is assessed and those involved in their care can access it. This includes contractors.

Put in place strategies to help workers to use the information management system* well.

Make sure all workers and others involved in a person’s care can access your information management system*. Make sure their access to your system* is appropriate to their role. This includes any system* workers or others, such as Commission Quality Auditors, use. This also includes any policies* and procedures*. Check with workers and others that they can access the information management system*. If they can’t, make sure you give them access.

Make sure policies* and procedures* support people to use your information management system*. Make sure these are:

• current and informed by the latest contemporary evidence-based practices*
• regularly* reviewed
• clear and accessible for workers and others involved in care and services.

Provide workers with guidance and training on how to use the information management system* (Outcome 2.9). This includes training to support digital skills if needed. This needs to be in line with:

• the organisation’s policies* and procedures*
• workers’ roles and responsibilities*.

Make sure workers understand:

• their role in the information management system*
• how to use the system* to safely manage information about older people and their care and services.
   

The guidance for Outcomes 2.8 and 2.9 has more information on workforce* planning and human resource management.

Monitor how well you use the information management system*.

Regularly* review your information management system* to make sure it works well. Look for ways to improve the system*. To check if you’re managing information well, you can review:

• older people’s care and service plans* (Outcome 3.1)
• complaints and feedback* (Outcome 2.6)
• incident* information (Outcome 2.5)
• worker* performance and how well they’re using the information management system*. You can do this through quality assurance and system* reviews (Outcome 2.9).
• policies* and procedures*.

If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, be open about it. Share what went wrong with older people, their family, and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.

The guidance for Outcome 2.3 has more information on monitoring the quality system*.