The purpose of this policy and procedure is to ensure case notes are accurate, timely, objective and support safe, high-quality service delivery, accountability and continuity of care.

This policy and procedure applies to all staff who document participant information and meets relevant legislation, regulations and Standards.

Applicable NDIS Practice Standards

Information Management

Outcome

Each participant’s information is managed appropriately and securely.

Indicators

• Records are accurate, complete and current.
• Information supports continuity of supports and safeguarding.
• Systems protect participant privacy and confidentiality.

Provision of Supports

Outcome

Each participant receives supports that are appropriate to their needs and circumstances.

Indicators

• Case notes reflect service delivery accurately.
• Records support monitoring, review and improvement of supports.

Definitions