Contents

Before you begin vii

Topic 1 Determine personal support requirements 1

1A Review individualised plan 2
1B Identify requirements outside of scope of your own role and seek support 17
1C Consider the potential impact that provision of personal support may have
on the person 22
1D Consider specific cultural needs of the person 28
1E Consider specific physical and sensory needs of the person 30
1F Identify risks associated with the provision of support and confirm with
supervisor 32
Summary 39
Learning checkpoint 1: Determine personal support requirements 40

Topic 2 Maximise participation 43

2A Discuss and confirm the person’s own preferences for personal support 44
2B Consider and confirm the person’s level of participation 48
2C Provide the person with information 52
Summary 54
Learning checkpoint 2: Maximise participation 55

Topic 3 Provide personal support 57

3A Safely prepare for each task 58
3B Take account of identified risks in the provision of personal support 66
3C Identify and respond to routine difficulties during support routines 88
3D Identify changes in the person’s requirements 90
3E Work with the person and supervisor to identify required changes to
processes and aids 99
3F Maintain confidentiality, privacy and dignity 103
Summary 107
Learning checkpoint 3: Provide personal support 108

Topic 4 Complete reporting and documentation 111

4A Comply with the organisation’s reporting requirements 112
4B Complete and maintain documentation 116
4C Store information 123
Summary 126
Learning checkpoint 4: Complete reporting and documentation 127

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 CHCCCS011 MEET PERSONAL SUPPORT NEEDS

Situation

Different clothes are required for different occasions. For some people, it is very
important to be well dressed if they are going to a social event, seeing a doctor or
meeting other professional people.

Personal ability

It is important that people are wearing clothing that they can manage. For
example, they should not wear clothing that prevents them from going to the toilet
independently. Velcro or hook fastenings, pants with elastic waists instead of clothing
with buttons or zips may be more suitable. An occupational therapist may find ways
for people to manage things like buttons, zips and other fastenings.

Grooming
Personal hygiene and grooming maintains a person’s health,
appearance and general wellbeing. It means keeping their bodies
clean, free of dirt, and looking and smelling fresh. Personal hygiene
involves washing and oral hygiene to keep the body clean. Grooming
involves making sure clients’ clothes are neat and tidy, their hair is
brushed, fingernails are clean, men are clean-shaven, and women

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have their make-up on where this is their preference.

Ensure grooming is appropriate

Where possible, ask the person or their carer what they are doing for the day to
make sure their grooming is appropriate. Always tell the person what you are going
to do before you do it. Check the person when they have finished their grooming to
see that they have not forgotten something. Tell them they look good. It is reassuring
for someone who cannot do their own grooming to know they look good, and that
someone else is checking for them and cares about how they look.
Some of the reasons why grooming people may be required are outlined below.

Physical disability

XX A person with a physical disability affecting the use of their arms or shoulders
may have difficulty lifting their arms to brush or comb their hair, apply make-up
or hold a shaver.

Vision problems

XX A person with vision problems may have difficulty seeing if their hair is neatly
combed, their face smoothly shaven, their make-up neat and natural or if their
nails are clean.

Dementia

XX A person with dementia may have forgotten how to groom themselves

appropriately and regularly.

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Some reasons that people may need assistance with hydration, nutrition or feeding are
shown below.

Mobility limitations
People may have difficulty mobilising or standing and cannot
prepare a meal or get a drink.

Memory problems
Memory problems mean that people sometimes forget to eat and
drink properly, or they cannot safely prepare a meal.

Parkinson’s disease
Conditions such as Parkinson’s disease may mean that people are
unable to chew or swallow properly and cannot feed themselves.

Physical disability
People may have physical disabilities and are therefore unable to
feed themselves.

Teeth or dentures
Sometimes problems with teeth or dentures mean that assistance
with feeding is required.

Arthritis
Conditions such as arthritis can make food preparation painful, so
people need support to prepare their meals.

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 Topic 1 Determine personal support requirements

Service agreements

XX Services in receipt of funding from Government departments or through funding

that is attached to the individual (for example; care package or individualised
funding options) are required to have the planning processes established
and operating according to set time frames. Plans generally form part of the
standards for each service type.

Scope of role and responsibilities

Example

John is a support worker at a special development school where Ricky is a student.

Ricky is 8 years old and has Down syndrome. He is unable to perform most of his
own personal care tasks. Ricky loves having his shoes and socks off, and has always
needed someone to put them back on for him when he goes outside or is ready to go
home.
Ricky’s personal support plan states that staff should provide full assistance to Ricky
when he requires his socks and shoes to be put on.
Today when John is getting Ricky ready to go outside and play, he notices that Ricky
has found his shoes and socks by himself and has started to pull them on. He cannot
pull them up properly, but has at least got them part of the way on. John notes this
observation in Ricky’s case notes but it is beyond his responsibility to modify Ricky’s
personal support plan. He talks to his supervisor about getting Ricky’s personal
support plan changed to instruct workers to encourage Ricky to put his own socks on
and assist only when he has done as much as he is able.

Practice task 2
Read the case study, then answer the questions that follow.

Case study
Mrs Richmond is a 71-year-old woman who lives in a unit in a retirement village.
She has always cooked her own meals and baked cakes and scones for herself,
her family members and friends. Lately she has been experiencing some memory
loss. Staff from the village have been called to her unit three times to respond to a
smoke alarm. They discovered that she had forgotten to take things out of the oven
and they had become burnt and set off the alarm. When staff attended the unit,
they noticed that Mrs Richmond’s kitchen was dirty, she had out-of-date food in the
fridge and she did not seem to have washed properly.

What is the context of Mrs Richmond’s requirement for personal support and how does
this impact the way support services could be provided?

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 Topic 1 Determine personal support requirements

Changes to a client’s language support requirements

Example
Mrs Kieselbach is an 80-year-old woman who was born in Germany. She moved to
Australia with her husband when she was 28 years old. Mrs Kieselbach has moderate
dementia, which is slowly worsening.
Lin is the support worker who has visited Mrs Kieselbach twice a week for the past
six months. Mrs Kieselbach has always enjoyed Lin’s visits as they have common
interests and have a lot to chat about. Over the last few weeks, Lin has noticed Mrs
Kieselbach sometimes starts to talk to her in German instead of English. Lin has to
remind her to speak English. She has also noticed that Mrs Kieselbach sometimes
seems not to understand Lin, and Lin must repeat what she has said.
When Lin reports this to her supervisor, her supervisor suggests it is possible that as
Mrs Kieselbach’s dementia progresses, she is losing her ability to speak English and
will gradually revert to German. Lin and the supervisor arrange for a German-speaking
worker to meet Mrs Kieselbach.

Practice task 4
Read the case study, then answer the questions that follow.

Case study
Mr Pukitas was born in Latvia and moved to Australia with his wife and three
children when he was in his late 30s. He always insisted on maintaining a number
of Latvian traditions in his family. He only spoke Latvian to his wife, and spoke
Latvian to his children as often as possible. He has been a member of the Latvian
Social Club ever since coming to Australia. Mr Pukitas is now 83. Since his wife died
five years ago, he has lived on his own in a small apartment. His children all live
interstate or in the country.
Mr Pukitas can no longer drive, and needs assistance with emptying his catheter
bag, so he cannot attend the Latvian Social Club on his own any more. His Latvian
friends that lived nearby have all either passed away or moved away. It is very
important to him that he maintains contact with others from his country of birth
and has a community he can participate in and celebrate Latvian traditions and
culture. When the local home support service provider assesses Mr Pukitas, they
document this as one of his needs. The service provides assistance with transport
and personal care to ensure that Mr Pukitas is able to attend the Latvian Social
Club and remain involved in the Latvian community.

1. What type of cultural need does Mr Pukitas have?

2. How have his activities of daily living changed in relation to this need?

3. What did the home support service do to meet Mr Pukitas’s needs?

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 Topic 1 Determine personal support requirements

Here is more information about duty of care.

Duty of care

XX Duty of care is the obligation a person has to act in a way that would not cause
harm.

Negligence

XX Negligence occurs when duty of care has been breached and harm to
either person or property ensues. It is the legal and ethical obligation of any
community worker, supervisor or organisation to ensure that people using
services are not exposed to unnecessary or unreasonable risk.

Dignity of risk

XX The rights of people to dignity and choice, upheld in legislation and service
standards, also require that duty of care or safety is not used as a reason to
limit a person’s freedom or personal choice. A support worker’s adherence
to duty of care and safety must be coupled with the concept of dignity of risk,
which means that a person has the right to make their own choices and to take
risks.

Risks or potential risks when providing support

It is important that, as a support worker, you are constantly assessing situations
and tasks for potential risks and identifying them where they occur. When providing
personal care, the people you work with are vulnerable to injury or harm and need
to be protected from this. In identifying and dealing with risks, you are preventing or
reducing the likelihood that the people you provide support to, their family members,
other staff and yourself will come to harm.
Risks may be simple risks or major risks, and the solutions to these will differ. The
types of risks you may experience are described below.

Evidence of self-neglect

Self-neglect is when a person is not looking after themselves properly. For example,
you may notice that they are losing weight and that the food in their fridge or
cupboards is not being eaten; they may not be washing themselves properly or often
enough; and they may not be wearing clean clothes. While some of these signs on
their own may not seem important, they may indicate the person requires additional
support or is unwell. They can be signs that the person is neglecting themselves and
is at risk of becoming weak or sick. Self-neglect can be a major risk and you should
report any signs of this to your supervisor as soon as possible.

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 Topic 1 Determine personal support requirements

Hazard report form

Example Hazard report form

Date of report 29 May 2016
Person reporting hazard Marina Pappas
Names of people involved Joe Chalmers
Location of hazard Joe’s bathroom, at home
Description of hazard (include area and When assisting Joe with his shower
task involved and any equipment, tools, today, I noticed that the tiles on the wall
people involved) of his shower are loose and may fall off
the wall if knocked.
Immediate or suggested actions I showed Joe and his carer the area
(list any suggestions for reducing or where the tiles are loose and ensured
eliminating the problem) they understood the risk and agreed
not to enter the shower without
supervision. I placed a large printed
notice on the door of the shower to
remind him not to enter. I wrote a note in
the communication book to alert other
support workers and the rest of the
family of the risk. Reported to supervisor
via phone.
Person incident reported to Wendy Stewart, Home Services Team
Leader
Signature Marina Pappas

Remove or reduce risks

Some risks can be removed. For example, another
example might be removing a rumpled or creased
rug to prevent a client tripping on it.
Some risks cannot be removed. Where this is the
case, it is important to control the risk. You need
to plan to make sure the risk does not cause
harm. An example might be placing a sign to warn
people of the danger. The edges of a cracked or
damaged path could be spray-painted in a bright
colour to ensure they can be easily seen and
avoided. These steps may help to reduce the risk
and make the situation safer for everyone.

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Topic 2 Maximise participation
In this topic you will learn When working with people who have personal care
how to: needs, it is important to do all you can to ensure they
are active participants in their own care. A good way to
2A Discuss and confirm
check whether the person is participating in their care
the person’s own
is to ask yourself: ‘Am I doing this task for the person or
preferences for personal
with the person?’ When you do something for someone,
support
this implies they are a passive participant – they are not
2B Consider and confirm an active participant, directing or choosing what is done.
the person’s level of When you do something with someone, this implies you
participation both have an active role. There is discussion, choice and
mutual activity in completing the task.
2C Provide the person with
information

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 Topic 2 Maximise participation

Practice task 7
You are the support worker assisting Simone. Read this care plan for Simone, then
answer the questions that follow.

Support plan
Person Simone Dean
Age 34
Diagnosis Acquired brain injury
Some lower limb weakness
Memory loss
Intellectual disabilities
Personal care Needs assistance with appropriate clothing choice
Can shower independently; however, requires monitoring (from
outside the bathroom) and prompting to wash hair and not stay in
the shower too long (five minutes)
Needs assistance to dry feet
Needs assistance to dry hair with hair dryer
Can dress independently except for small buttons, hooks and
eyes, and shoes and socks
Requires supervision and prompting to make and eat breakfast –
especially if using electrical appliances
Requires assistance with preparation of suitable lunch and
snacks to take to the adult training support service (ATSS)

1. Write down what you might say to Simone to confirm her preferences when you
arrive to assist her.

2. Pick one task from the list and write a detailed description of the steps required, as
you would describe them to Simone.

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 CHCCCS011 MEET PERSONAL SUPPORT NEEDS

Here is more information about aids that assist in lifting and transferring people safely.

Hoists
Hoists are used to transfer people. A person may be transferred
from a wheelchair to a bed, a bed to a chair, or from a chair to a
swimming pool. Hoists can be portable, moving easily from place
to place and operated by remote control. Using a hoist properly
means the worker does not need to lift the person; they guide the
person from one place to another.

Handrails
Many people rely on handrails to assist them to stand up or sit
down. These may be on the wall close to a bed, shower, bath or
toilet. Handrails are usually made of rounded metal so they can be
gripped easily. They should be at the right height and angle for the
person. An occupational therapist usually assesses the best place
and height for handrails in a person’s home.

Beds
Adjustable beds are available for people who have difficulty getting
in and out of bed. Some beds can be raised or lowered depending
on the person’s needs. Sometimes it is necessary to adjust the
height of a bed or raise the head of the bed to assist the person to
sit up or get out of it, or to assist in providing personal care such as
dressing or bed bathing.

Scales
Scales are used to monitor a person’s weight. People who can stand independently
may be able to be weighed using regular bathroom scales. For people who are unable
to easily stand, there are scales that are attached to a chair or hoist sling. The person
is assisted to sit or lie comfortably in the chair or sling and, once still, their weight is
recorded. If you are concerned about a change in a person’s weight, record this in
their care notes and inform your supervisor so that the person can be assessed and
equipment adjusted to better meet their needs.

Continence aids
There are a range of continence aids you may be required to use. You may also need
to change sheets or bedding. Many beds have a plastic sheet under the regular one.
This stops urine reaching the mattress. You must wear gloves when changing pads or
underwear or cleaning continence aids.
Here are some of the types of continence aids.

Pads or special underwear

XX Common continence aids include pads or special underwear, which need to be

changed regularly.

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Personal protective equipment (PPE)

Personal protective equipment (PPE) is anything used or worn by a person to minimise
risk to the health and safety of that person. PPE may include special clothing, shoes,
masks, hats, gloves, goggles and a range of other protective wear.
In the community services environment, PPE is often used as a standard precaution
to prevent the spread of infection and disease. The Model Work Health and Safety Act
and Regulations (2011) outline that PPE must be worn by all workers if it has been
provided by the employer and is required as part of any workplace policy, procedure or
work practice.
The following PPE is commonly used to prevent the spread of infection and disease in
the community services environment.

Gloves

Gloves must be worn whenever you are likely to come into direct contact with blood,
body fluids, mucous membranes, non-intact skin and other potentially infectious
material.
Gloves should also be worn whenever you handle or touch visibly or potentially
contaminated items and surfaces, such as soiled linen or used tissues.
Once you have finished the task that required the use of gloves you should remove
and dispose of them within the contaminated area. You should then wash your
hands and apply fresh gloved before moving between a contaminated body site and
a clean body site, and before touching clean items or surfaces.
It is a standard precaution that hand hygiene must be performed before and after
glove use.
When using gloves, remember that disposable gloves are intended for single use
only and should be considered contaminated once they have touched a surface,
person or site that is considered unclean.

Gowns and aprons

In some workplaces an apron or gown may be required depending on the potential

risk of contact with infectious material and the potential for blood and body
substances to penetrate through the clothes to the skin.
You may be required to wear a clean non-sterile apron or gown to protect skin and
prevent soiling of clothing during procedures and/or care activities that are likely to
generate splashing and/or sprays of blood or body substance.
You may be required to wear a long-sleeved fluid impervious gown if there is a risk
that clothing may become contaminated with blood and body substances, secretions
or excretions.
Remember that once you have used a gown or apron, you should assume it is
contaminated and should therefore remove the apron/gown and perform hand
hygiene before moving between environments.

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Fall recovery steps

Do not hurry
1 Do not hurry, and let them rest as often as they need to. If they get stuck at
any time, make them comfortable and call the ambulance.

Take time
2 Do NOT try to get the person up straight away.

Be calm
3 Calm the person and yourself. Get them to take deep slow breaths.

Check for injuries

4 If they are badly injured, such as with a broken bone, they need to stay where
they are. Make them as comfortable as possible and call an ambulance. Keep
them warm while you wait for the ambulance.

Check capability
5 If they are not badly injured and feel they could get up, get two sturdy chairs
and place one near the person’s head and one near their feet.

Guide lightly
6 It is important that the fallen person does the work. You should only guide
lightly, helping the person to roll onto their side.

Direct the person to kneel

7 Help the person to kneel. If they have sore knees, place a towel underneath
as cushioning.

Place a chair
8 Place one chair in front of the kneeling person.

Use chair
9 Ask the person to lean on the seat of the chair and bring one leg forward and
put that foot on the floor.

Place a second chair

10 Place the second chair behind the person. Ask them to push up with their
arms and legs and then sit back in the chair behind them. Guide them up and
back into the seat, remembering not to lift them – they should be doing the
work. Keep your back upright.

Report
11 Let the person’s doctor know that they have had a fall.

(Adapted from Australian Government Department of Health and Ageing at: www.health.gov.au/internet/
publications/publishing.nsf/Content/dff-toc~dff-surroundings~dff-surroundings-getup)

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 CHCCCS011 MEET PERSONAL SUPPORT NEEDS

3C Identify and respond to routine

difficulties during support
routines
While it is important that workers provide assistance to people as directed in the
personal support plan, there are occasions when it is difficult to meet a person’s
needs for support.

Sources of difficulty in meeting a person’s needs

XX Organisational limitations
XX The personal care support plan
XX Your own skills and knowledge
XX The person’s behaviour, preferences or abilities

Capacity to meet a person’s needs

The organisation you work for may not have the
capacity to cater to the person’s needs. If this is
the case, inform your supervisor of the identified
need that is unable to be met so the person can
be referred to a service that can meet this need.
If the person’s support plan does not address
a need that the person requires and the need
is something that you could meet, the person’s
needs should be assessed and their support plan
revised.
Where there is a need that you are unable to meet
because you lack the skills and/or knowledge,
you may be able to seek support for training as part of your regular appraisal with your
supervisor. If there is a need that is to be met immediately, inform your supervisor that
you require training as soon as possible.

Difficulties relating to a person’s behaviour

If the difficulty is related to the person’s behaviour, preferences or abilities, assess
the situation and the reasons behind the difficulty. When you encounter difficulties in
providing personal care, consult with the person and try to involve them in determining
their needs and planning their support. This can work well when the person is able to
provide a true account of their difficulties.
If you are able to deliver the required support to the person according to the support
plan and still respond to the person’s behaviour or preference, then adapt the
support to meet their need. Conditions such as mental illness, intellectual disability or
dementia can affect a person’s ability to clearly express their needs. If you are unable
to meet their need, deal with their behaviour or deliver the care required, contact your
supervisor to discuss the situation and receive advice about dealing with the situation.

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observant and report any changes, you do not have to know or try to diagnose what is
wrong. Do not try to treat a medical or physical change unless you have been trained
for this.
Here are some signs that may indicate change in a person’s behaviour.

Signs of potential change in a person’s behaviour

XX Lacking motivation – the person is not interested in anything

XX Crying a lot or looking sad
XX Being excessively happy or full of energy
XX Doing risky or dangerous things
XX Being forgetful or vague
XX Being angry or violent

Assessment tools
A variety of tools can be used to assess physical, mental and cognitive wellbeing,
and a person’s ability to carry out activities of daily living (also known as ADLs).
Doctors, nurses, psychologists and your supervisor should interpret the results of the
assessments to identify the person’s progress.
Types of tools used to assess a person’s needs include:
XX personal information questionnaires XX psychosocial needs forms
XX functional ability assessment forms XX mental health and wellbeing forms

XX health condition assessment forms XX mental status examinations.

Discuss and consult

Consultation about a person’s condition and progress can be verbal, written, informal
or formal. It needs to happen between all parties working with the person, as shown
below.

Team members and support staff

You may need to discuss the person’s progress with other support workers. Ensure
you speak about the person only with those involved in their care. If you need to seek
the expert advice of a worker or professional not involved in their care, you should
not refer to the person by name and only speak in general terms so that the person
remains anonymous, or seek the person’s permission to discuss their care.
Program planning meetings are formal ways to discuss and consult with all
stakeholders (those involved in the care and support of the person). These meetings
may be known as case conferences or program support groups. These meetings
offer all stakeholders the chance to share information about the person’s condition,
consider possible solutions and decide on a service delivery plan.

People and their carers

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A written case note

Example
Person/client’s Mrs Kieselbach
name:
Date: 23/04/16
Worker name: Lin Mai
Notes: Attended Mrs Kieselbach today. Personal care support was
provided as per the care plan.
Mrs Kieselbach began to speak to me in German a number
of times today. When I reminded her to speak English, she
switched back to English. A number of times I had to repeat
things as she appeared not to understand me.
This change was reported to Sue Kelly, supervisor, by phone.
Sue will discuss the change with the doctor, and possibly
arrange for transition to German-speaking workers.
Signature: Lin Mai

Report concerns about a person’s health

You must report every change that affects a person’s care needs. Do not assume
someone else will see the change or that it has already been reported. Dealing with
health issues early may reduce their longer-term impact.
A change to the person’s health or a change that is likely to affect their health must
be reported to your supervisor who will take appropriate action, perhaps after making
their own assessment of the situation.
Where a change in the person’s health means they are at immediate risk of harm
or permanent damage, you may need to act quickly to provide first aid and call for
emergency assistance. Once the situation has been stabilised, you should make
urgent contact with your supervisor to receive instructions about what actions to take
next and to ensure the person receives the support they require.
Your organisation will have specific policies and procedures that you must follow when
reporting to your supervisor on a person’s condition. Often the best course of action is
to make a verbal report, but you should always put your observations in writing using
the appropriate documentation.

Incident reports
An incident report is a form that is filled out if there has been an incident or event
(something that has happened to cause an accident or injury). A near miss (something
that almost causes an injury or accident) should also be reported.
All workplaces have incident report forms. Your supervisor can tell you where they
are kept in your workplace. Make sure you fill in all the relevant sections using clear,
simple language. Record exact details, writing down only what you saw, did or were
told.

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Confidential information
Often you need to share a certain amount of
information in order to provide care that best
meets the person’s needs. Discussing the
person’s needs and personal information with
others who are directly involved in supporting the
person and who you know have permission to
access the person’s information is not breaking
confidentiality.
People supported through a community or
residential support service may sign a statement
or agreement that acknowledges they have read
information about their rights and responsibilities
in relation to privacy and confidentiality. Often this will be an agreement to have their
personal information collected and shared with others directly involved in planning and
providing their care. This is often referred to as ‘consumer consent’.
When you commence work as a support worker at any organisation or agency, you may
also need to sign a confidentiality agreement to show you understand and agree to
comply with the workplace policies and guidelines about confidentiality and privacy.

Consumer consent form

Example

Consumer consent
To ensure the consumer is able to make an informed decision about Initial
consent to the disclosure of their information, the worker should: when
completed
XX Discuss with the person the intended use of the information
collected.

XX Explain that the person’s information will only be released to

those staff/services directly involved in the person’s care.

XX Provide the person with information about privacy.

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 CHCCCS011 MEET PERSONAL SUPPORT NEEDS

Learning checkpoint 3
Provide personal support
This learning checkpoint allows you to review your skills and knowledge in providing
personal support.

Part A
The following table includes changes that a support worker might notice. For each one,
tick whether it is a major or minor change and how it should be acted on or reported.

Change noticed Major Minor How would you act on the situation
and report it?
The person has an itchy rash
all over their back

The person’s family are on

holiday

There is a tap that won’t stop

dripping

The person falls and cannot

get up

The person’s dog has run away

A tree has fallen down over the

person’s driveway

The person’s grandson has

moved into the home

The person is unusually angry

and aggressive

The person’s phone is out of

order

The person tells you they now

have a case manager

The person reports feeling sick

and dizzy and appears pale

The person says they do not

feel hungry today

The person is having difficulty

with the buttons on their
clothes
The person is using a walking
stick, but is becoming
increasingly unsteady on their
feet

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Incident and accident reports

XX All support workers have work health and safety responsibilities. Communicating
with others about risks is part of these responsibilities. If you witness a
workplace accident involving a person, you may be required to fill out an
accident report form. Recording near misses or incidents also assists in making
improvements to workplace safety to minimise hazards or risks.

Comply with organisational reporting requirements

Example

Sara is an older person. One day her support worker, Lois, finds her on the bathroom
floor. Sara said she tripped over. Lois helps Sara up and makes an appointment with
her doctor.
Then she completes this form.

Accident/incident report form

Section 1: Witness details
Last name: Johnson Given name: Lois
Worker  Visitor  Client  Contractor 
Phone number: 03 5411 1111
Section 2: Details of injured person
Last name: Apora Given name: Sara
Gender: M F
Worker  Visitor  Client  Contractor 
Was the person injured? Yes  No 
Go to Go to Section 4
Section 3
Section 3: Details of injury
Date: 23/02/2016 Time: Approximately 8 am
Location (on the person’s body) Bruising – Where did the Bathroom
left hip injury occur? floor
How did the injury occur? The client Was the witness Yes ¨ No
reported present at the þ
that she time of the
tripped accident?
over.
Was medical help sought? Yes  No 
If yes, provide details Name: Jake Black,
MD
Contact details:
Phone:
25 Kalinga St, Bendigo
5555 2222
If no, explain why not
Witness’s name: Lois Johnson
Witness’s signature: L. Johnson

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Use correct form

Use the appropriate form. This helps other workers identify the required information.
Make sure you have completed all sections and entries make sense.

Check information
Read information back to the person and/or their advocate to confirm its accuracy.
While this may take extra time, clarifying information helps prevent mistakes that may
take considerable time and effort to rectify.

Sign and date

Records should be signed and dated by the person completing them. Computer-
based records may require a log-in to access records that identify the author.

Write reports
If you are not sure how to write reports, check with your line manager about the
guidelines to follow.
Here are some tips to keep in mind.

Tips to assist in report writing

XX Use the correct format; check if there is a template.

XX Use the organisation’s letterhead when appropriate.

XX Follow protocols about using organisational stationery.

XX Use correct terminology for your audience; for example, funding applications are
different to reports for a person using your service.

XX Ensure all reports are objective, accurate and easy to read.

XX Ensure your reports are sending a professional message; use appropriate

language, presentation, grammar and spelling.

XX Show drafts to another authorised person for feedback.

XX Some organisations have a requirement that any outgoing reports are signed off
by a manager.

Maintain documentation
Recording and documenting work is an ongoing task. Documentation should not be
allowed to get out of date. It must be completed as the work is done to prevent errors
or omissions. It could be required at any time by other workers, by your supervisor,
government agencies or for legal proceedings.
Generally, records of past work are stored and maintained even if they no longer
appear relevant, or have been superseded by more recent information. These
documents may be required to assess changes in a person’s needs over time; to
demonstrate past support or to show a history of quality care. Your workplace will have
procedures and guidelines about how and when documentation is to be completed.

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Organisational policies and procedures

Stored as a reference for obligations of the organisation and
workers, to ensure information about policies and procedures is
accessible and up to date.
This information may be in hard copy and provided to staff. In
some organisations, policies and procedures are only available
electronically to ensure the most recent records are used.
Case files and information
Stored so a plan can be developed and implemented to meet
individual needs and to meet duty of care and other legal
requirements.
This information may be stored in a locked filing cabinet or
password-protected database or electronic files with limited
access.
Staff information
Stored so human-resource functions (recruitment, induction,
professional development and performance appraisal) can be
implemented to meet duty-of-care and work health and safety
obligations.
This information may be stored in a locked filing cabinet or
password-protected database or electronic files with limited
access.

Update information
There may be times when additional information is required to meet new standards.
For example, when privacy legislation was introduced, community services providers
had to get both existing and new people who used their services to sign ‘consent to
disclose information’ forms. If they did not do this, it would be illegal for the service to
share this information with other agencies. It is extremely important to regularly review
and update all information to ensure it complies with all identified requirements.

Store the information

Information should always be kept in safe and secure areas. You must always follow
organisational procedures for filing information. Personal information
should not be kept in an area accessible to others.
There will be policies and procedures about where reports and
documents should be filed or stored, so they can be easily located
and referred to. Many organisations use electronic systems that
record client details, referrals, assessments and case notes in a
client database. To protect the client’s privacy and confidentiality,
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files are password-protected, so only authorised people can access

the information.

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