Why is information management critical in aged care?
Outcome 2.7 explains providers' obligations to have an information management system to safely manage the information of older people with their informed consent. Timely access to the right information at the right time supports workers, older people, their supporters, registered health practitioners and allied health professionals to deliver quality care and services tailored to each person's needs.
According to the Strengthened Aged Care Quality Standards guidance, information management systems must ensure information is confidential, secure, identifiable, current, accurate and integrates information from different sources. Providers need to regularly review and improve how effective their information management system is, including current technologies and data practices.
Key focus areas for Outcome 2.7
| Access to information | Ensuring workers and others involved in care can access the right information at the right time |
| Accuracy and completeness | Making sure information is current, accurate and complete |
| System effectiveness | Regularly reviewing and improving the information management system |
What does the outcome statement require?
The provider must ensure that information recorded about individuals is accurate and current, and able to be accessed and understood by individuals, supporters of individuals, aged care workers, registered health practitioners, allied health professionals and others involved in the individual's care.
The provider must ensure information is kept confidential and managed appropriately, in line with informed consent.
Training requirements by role
| Role | Key training areas | Recommended Ausmed modules |
|---|---|---|
| Governing body and senior leadership |
Understanding accountability for implementing and maintaining effective information management systems Monitoring effectiveness through quality system reviews Ensuring compliance with privacy laws and data protection Managing cyber security risks Planning for adequate data storage and system capacity |
Standard 2: The Organisation (15 min) Strengthened Aged Care Quality Standards (30 min) Cyber Security (20 min) Responsible Person Duty in Aged Care (15 min) |
| Clinical and care managers |
Implementing processes for recording and managing information Monitoring worker performance in using information systems Ensuring clinical information systems are used effectively Facilitating access to information during transitions of care Coordinating information sharing with external providers |
Documentation in Aged Care (25 min) Privacy, Confidentiality, Dignity and Personal Information in Aged Care (22 min) Communicating in Aged Care (24 min) Understanding Care Plans in Aged Care (26 min) Cyber Security (20 min) |
| Registered nurses and health practitioners |
Using clinical information systems to record and manage clinical information Documenting assessment and planning information accurately Recording Quality Indicator data where applicable Ensuring medication management information is current Providing accurate information during transitions of care |
Documentation in Aged Care (25 min) Understanding Care Plans in Aged Care (26 min) Privacy, Confidentiality, Dignity and Personal Information in Aged Care (22 min) Transitions of Care for Older People (20 min) Incident Report Writing (30 min) |
| Care workers (including personal care workers, assistants in nursing) |
Accessing and using the information management system appropriately Recording information about care and services accurately and timely Monitoring and recording preferences, function and changes during activities of daily living Maintaining confidentiality and privacy of information Communicating information effectively at handover and transitions |
Record Keeping and Documentation for Non-Clinical Staff (10 min) Documentation in Aged Care (25 min) Privacy, Confidentiality, Dignity and Personal Information in Aged Care (22 min) Communicating in Aged Care (24 min) Person-Centred, Rights-Based Care for the Older Person (12 min) |
| Administrative and IT staff |
Maintaining and supporting the information management system Managing cyber security risks and implementing protective measures Supporting digital literacy and system access for all workers Implementing backup systems and processes for offline access Complying with privacy laws and data protection requirements |
Cyber Security (20 min) Privacy, Confidentiality, Dignity and Personal Information in Aged Care (22 min) Record Keeping and Documentation for Non-Clinical Staff (10 min) |
Implementation guidance for training
Induction training
All new workers should complete information management training during induction, covering:
- How to access the information management system
- Role and responsibilities in recording information
- Privacy, confidentiality and informed consent requirements
- Policies and procedures for information management
- System downtime protocols - what to do when systems are offline or unavailable
Ongoing competency development
Regular refresher training should be provided to:
- Update workers on changes to systems, policies or procedures
- Address performance issues identified through quality assurance reviews
- Support digital skills development for workers who need additional assistance
- Reinforce the importance of accurate, timely and complete documentation
- Review cybersecurity awareness and data protection practices
Role-specific training
Training should be tailored to specific roles and responsibilities:
- Clinical staff need detailed training on clinical information systems and assessment documentation
- Care workers need practical training on recording activities of daily living and changes in condition
- Agency workers and contractors need training on accessing and using the organisation's specific systems
- Visiting health practitioners need information on how to access relevant records
Service-specific considerations
For home and community care providers
The Strengthened Standards guidance notes that for home service 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 rather than requiring a dedicated clinical information system.
Training focus areas for home care workers:
Effective communication between older people, workers and organisations, even without direct or face-to-face interactions
Recording information remotely or in the community
Coordinating information with multiple service providers and associated providers
Ensuring continuity when different workers provide care
For residential aged care providers
Residential providers have additional requirements for clinical information systems and recording Quality Indicator data.
Training focus areas for residential care:
Using digital clinical information systems where possible
Recording Quality Indicator data
Monitoring and documenting preferences, function and changes during activities of daily living
Coordinating information during transitions between hospital and residential care
Providing care statements to individuals
Evidence for audit readiness
To demonstrate compliance with Outcome 2.7, providers should be able to present the following evidence:
| Evidence type | What to demonstrate |
|---|---|
| Training records | All workers have completed information management training appropriate to their role, including competency assessments for using information management systems |
| Policies and procedures | Current, accessible and regularly reviewed policies and procedures for information management |
| Care records | Examples demonstrating accurate, complete and timely documentation |
| Consent processes | Evidence of informed consent processes for information collection and sharing |
| System reviews | Regular reviews and improvement plans for the information management system |
| Cyber security | Cybersecurity policies and worker training records |
| Quality indicators | Quality indicator data records (where applicable) |
| Offline access processes | Processes for accessing critical information when digital systems are offline |
| Performance reviews | Worker performance reviews that include assessment of information management practices |
Connection to other outcomes
Outcome 2.7 intersects with several other outcomes in the Strengthened Standards. Effective information management supports and enables compliance across multiple areas:
| Outcome 1.3 Choice, Independence and Quality of Life |
Information about the older person's care supports them to make informed decisions |
| Outcome 1.4 Transparency and Agreements |
Information about care, services and agreements must be current, accurate and easy to understand |
| Outcome 2.3 Accountability and Quality System |
Information management feeds into the quality system |
| Outcome 2.4 Risk Management |
Information about risks must be securely stored and managed |
| Outcome 2.5 Incident Management |
Incident information must be recorded and managed |
| Outcome 2.9 Human Resource Management |
Information from candidates and workers must be stored accurately |
| Outcome 3.1 Assessment and Planning |
Information from assessment and planning must be securely stored |
| Outcome 3.3 Communicating for Safety and Quality |
Critical information must be communicated effectively |
| Outcome 3.4 Planning and Coordination |
Information sharing is essential for coordinated care |
| Outcome 5.1 Clinical Governance |
The clinical information system is part of the clinical governance framework |
| Outcome 5.3 Safe and Quality Use of Medicines |
Medication information must be current and accurate |
| Standard 6 Food and Nutrition |
Nutritional needs information must be recorded and accessible |
| Standard 7 The Residential Community |
Information supports transitions and daily living |
Key takeaways
Effective information management is essential to delivering safe and quality aged care.
| Access and use - Workers must be able to access and use information management systems effectively for their role | |
| Accurate recording - Record information accurately, completely and in a timely manner | |
| Privacy and consent - Maintain confidentiality and obtain informed consent | |
| Effective communication - Communicate information effectively at transitions and handover | |
| Follow procedures - Follow policies and procedures for information management | |
| Cybersecurity - Protect information through cybersecurity awareness |
Training should be role-specific, regularly updated, and supported by clear policies, procedures, and ongoing competency assessments.
For more information about Outcome 2.7, visit the Aged Care Quality and Safety Commission's guidance page.
To assign training and track completion for your workforce, explore Ausmed's learning management solutions.
