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OPG Practices > Record Keeping > Flashcards

Record Keeping Flashcards

(63 cards)

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1
Q

What is the timeframe for creating a record of phone calls and running notes on Resolve?

A

24 hours of action taking place

This ensures timely documentation of actions taken.

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2
Q

How long do you have to complete or close a record of phone calls and running notes on Resolve?

A

48 hours

This allows for a brief period to finalize the record.

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3
Q

How often should running notes be updated after closure?

A

Never. A new running note must be created as an addendum.

This prevents reopening closed records.

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4
Q

What is the timeframe for creating an email record on Resolve?

A

24 hours of action taking place

Timely documentation of email communications is crucial.

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5
Q

When should an email record be completed or closed on Resolve?

A

48 hours

This timeframe allows for finalizing email documentation.

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6
Q

How should emails be handled in Resolve?

A

Drag and drop into Resolve and rename per naming convention

This maintains organization and clarity of emails.

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7
Q

What is the timeframe for creating a case summary for a new client?

A

7 calendar days

This allows for a comprehensive overview of the client’s situation.

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8
Q

When should a case summary be updated?

A

When a decision is made, when client circumstances change significantly, or every 6 months

This ensures the case summary remains current.

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9
Q

What is the timeframe for creating visit and meeting reports?

A

7 calendar days

This timeframe ensures timely documentation of meetings.

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10
Q

How long do you have to finalize decision reports?

A

7 calendar days of finalizing the decision

This ensures that decisions are documented promptly.

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11
Q

What is the best practice for completing decision reports?

A

Within 24 hours of starting the decision-making process

This helps in maintaining up-to-date records.

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12
Q

What is the timeframe for hearing reports (QCAT or MHRT)?

A

7 calendar days

Timely documentation is essential for legal compliance.

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13
Q

What is the timeframe for creating a Priority Rating Tool for a new client file?

A

8 weeks

This allows for thorough assessment and rating of client priorities.

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14
Q

When should the client front screen on Resolve be updated after saving the Priority Rating Tool?

A

At the time of saving the PRT

This keeps the client’s information current.

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15
Q

How often should the Caseload Tracker be updated?

A

Best practice is to update daily

This ensures that the tracker reflects the most current information.

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16
Q

What is the timeframe for creating a caseload tracker in eDocs?

A

Within 7 calendar days

This ensures that the caseload is actively monitored.

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17
Q

Is the caseload tracker ever considered completed or closed?

A

No, it is a living document

This allows continuous tracking of client caseloads.

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18
Q

Who is required to use the caseload tracker?

A

New Guardians who have not completed their induction program

This ensures they are actively managing their caseload.

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19
Q

What frameworks must be applied in all decisions?

A

The Structured Decision Making Framework, Human Rights Decision Making Framework, and relevant policies and practice directions.

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20
Q

What is structured decision-making?

A

A means for achieving the human rights of people with disabilities.

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21
Q

Why is structured decision-making mandatory for guardians?

A

It is a legislative obligation under the Guardianship and Administration Act 2000.

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22
Q

What should guardians consider when making decisions?

A

Risks to the adult and OPG.

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23
Q

When should a decision be recorded in a decision case?

A

If there is a reasonable likelihood of someone disagreeing with the decision, if it limits the adult’s human rights, or if it is considered significant.

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24
Q

What is the role of law guardians in decision-making?

A

Law guardians make decisions, provide reasons for them, and properly record them.

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25
Why are records of decisions important?
Records explain decisions to clients, inform future decisions, support guardianship reports, assist in supervision reviews, and fulfill external information requests.
26
What is a decision case?
A decision case records a guardianship decision with all relevant information and provides a clear rationale in one location.
27
How can some decisions be recorded to alleviate administrative workloads?
Some decisions can be recorded as a running note instead of creating a decision case.
28
What types of decisions may be recorded in a running note?
Decisions that present a comparatively lower risk to the adult and OPG may be recorded in a running note.
29
What is the default recording method for a decision?
A decision should be recorded in a decision case by default.
30
What should guardians consider when recording a decision in a running note?
Guardians should consider possible risks to the adult and the risk of complaints or disagreement about the decision.
31
What types of decisions must always be recorded in a decision case?
Specific decisions include: 1. Unknown or misaligned views, wishes, or preferences of the adult. 2. Likely disagreement or complaints from other parties. 3. Internal escalation or direction by Team Leader/Regional Manager. 4. Accommodation decisions. 5. Contact decisions. 6. Restrictive practices in aged care decisions. 7. NDIS decisions with core support and coordination by one provider. 8. Decisions to cease an NDIS provider or significant changes to NDIS support. 9. Supported Independent Living (SIL) decisions.
32
What criteria allow a decision to be recorded in a running note?
Decisions may be recorded in a running note if: 1. It is consent for a non-invasive assessment or information sharing as part of another decision. 2. It aligns with the adult's views and preferences, with no objections or specific concerns identified.
33
What is mandatory for guardians when completing a decision case?
Guardians must complete every field in a decision case.
34
What information must be included in every decision case?
1. Description of the adult’s circumstances leading to the decision. 2. The decision options. 3. Views of the adult and information from relevant stakeholders. 4. Reasons if the adult’s views were not obtained. 5. Reasons for excluding any interested party from consultation. 6. Relevant information from professionals. 7. Information from the Administrator (if applicable). 8. A clear statement of the decision made. 9. Explanation of alignment with the adult’s views. 10. Explanation of risks if the decision does not align with the adult’s views. 11. Justification for limiting the adult’s human rights.
35
What should be included if the adult's views were not obtained?
Detailed reasons why the views were not obtained.
36
What should be included if an interested party was excluded from consultation?
Reasons for the exclusion.
37
What type of information from professionals should be included?
Relevant information including copies of reports, such as ACAT assessments or social worker reports.
38
What is presumed to be applied in all guardianship decisions?
The Human Rights Act 2019 and General Principles.
39
Is it necessary to state that the Human Rights Act has been considered if no rights are limited?
No, it is not necessary to state this.
40
Is it necessary to explain which human rights have been promoted by the decision?
No, there is no need to explain this.
41
What should be included if the decision aligns with the adult’s views?
A brief statement explaining how the decision aligns.
42
What should be included if the decision does not align with the adult’s views?
1. Detailed explanation of how an alternative decision would be an unreasonable risk to health and welfare. 2. Explanation of how the General Principles were applied and justification for limiting human rights.
43
What must a decision in a running note be recorded as?
A decision must be recorded as a 'Running Note_Non complex Decision' within the adult’s active case.
44
Why is it critical to record decisions in a running note?
It is critical for reporting and statistical purposes.
45
What is outdated terminology regarding running notes?
The term 'non-complex' is outdated and will be updated within Resolve when modifications are available.
46
What minimum information must be included in a running note?
The following minimum information must be included: 1. Date of the decision 2. Summary of the decision and circumstances 3. Relevant views, wishes, and preferences of the adult 4. Relevant information from professionals and interested parties 5. Reference to other relevant documents or emails 6. All relevant information relied upon for the decision 7. Details of where documentation can be found in Resolve.
47
What should be documented in Resolve for a decision?
All relevant information relied upon for the decision must be documented in Resolve as per usual record-keeping expectations.
48
What is presumed in all guardianship decisions?
It is presumed that the Human Rights Act 2019 is applied in all guardianship decisions.
49
When is it unnecessary to state that the Human Rights Act has been considered?
It is unnecessary when no human rights are limited by the decision.
50
Is it necessary to explain which human rights have been promoted by a decision?
No, it is not necessary to explain which human rights have been promoted by the decision.
51
What should be noted if the decision aligns with the adult's views?
If the decision aligns with the adult’s expressed or demonstrated views, there is no need to explain that the General Principles have been applied.
52
What must be recorded about the adult's views, wishes, and preferences?
Information about the adult’s views, wishes, and preferences must be recorded in detail in all decision cases and running note decisions.
53
What should be included if referring to information in other documents?
The file name and details of where the documents are located on file should be included.
54
What to do if the adult's views cannot be determined?
If the adult’s own expressed views cannot be determined, possible conflicts of interest must be considered and documented in the decision.
55
What caution should be taken when using views from a third party?
Views obtained through a primary service provider should be used with caution if they would benefit financially from the decision or are subjects of concerns.
56
What must be included if a decision is made without knowing the adult's views?
A detailed explanation must be included in all decisions outlining the reasons why the views could not be obtained.
57
What to explain if the adult was not contactable and the decision was urgent?
Explain attempts made to contact the adult and reasons why the decision could not be delayed.
58
What reasons must be provided if urgent decisions do not allow for contact with the adult?
Reasons must be provided to why phone or video contact is not sufficient or details of unsuccessful attempts.
59
What must be documented if the adult cannot communicate due to severe impairment?
Details of the adult’s communication must be provided, along with an explanation of why alternative communication methods are not suitable.
60
What must be completed in decision cases regarding client consultation?
The mandatory field ‘Client consulted’ must be completed accurately.
61
When should 'Yes' be selected for 'Client consulted'?
'Yes' should be selected when views have been obtained from the adult, even if obtained prior to the decision.
62
What details should be included if views were obtained prior to the decision?
Detail should reflect when and how the views were obtained and why the guardian is satisfied the adult currently holds those views.
63
When should 'No' be selected for 'Client consulted'?
'No' should be selected where views were not obtained from the adult and the decision was made in their absence.

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