Table 7: Summary of actions related to the patient clinical record
Key: M = Mandatory actions; P = Appears under policies as well; T = Appears under training as well
This criterion will be achieved by:
12.3 Care planning and delivery based upon
assessment of consumer / patient needs.
12.6 Adopting a strategic and multidisciplinary
approach to managing and ongoing monitoring of
nutritional care for all consumers / patients.
12.8 Ensuring that appropriate clinical information is
made available in a timely manner to external
healthcare providers and consumers / patients to
facilitate ongoing care.
14.1 Addressing the needs of the organisation by
implementing systems to manage health records and
records created by the organisation.
14.2 Establishing a system to support the allocation
and maintenance of an organisation-specific
consumer / patient identifier for the first and every
subsequent visit to the organisation by a consumer /
patient to ensure continuity of care.
14.3 Clinical coding and classification that is
performed for all consumers / patients accessing
services in accordance with jurisdictional standards,
where available, or guidelines.
14.4 Implementing systems to ensure that consumer /
patient access to health records is in accordance with
jurisdictional policy / legislation.
Actions required:
12.3.1 Care planning and delivery are evaluated to
ensure that they are:
 effective
 comprehensive
 multidisciplinary
 informed by assessment
 documented in the health record
 carried out with consumer / patient consent and,
where appropriate, carer participation.
12.6.1 Food, fluid and nutritional care form part of
an intervention and clinical treatment plan.
12.6.2 Relevant healthcare providers use an
approved nutrition risk screening tool to assess
consumers / patients:
 on admission
 following a change of health status
 weekly thereafter
and referrals to nutrition-related services occur
when needed.
12.6.3 The adequacy of consumer / patient nutrition
is actively monitored and reported, and
improvement is made to the nutritional care as
required.
12.8.3 Results of investigations follow the consumer
/ patient through the referral system.
M
M
M
14.1.1 Health records management systems are
evaluated to ensure that they include:
 reference to all relevant legislation / standards /
policy / guidelines
 defined governance and accountability
 the secure, safe and systematic storage and
transport of data and records
 timely and accurate retrieval of records stored
on or off site, or electronically
 appropriate retention and destruction of records
 training for relevant staff in health records
management.
14.2.1 The system for the allocation and
maintenance of the organisation-specific consumer /
patient identifier, including a process for checking
multiple identifiers, is evaluated, and improved as
required.
14.3.1 Healthcare workers participate in the
analysis of data including clinical classification
information.
14.3.2 Clinical coding and reporting time frames that
meet internal and external requirements are
evaluated, and improved as required.
14.4.1 Consumers / patients are given advice /
written guidelines on how to access their health
information and requests for access are met.
P
T
M
1
2