Defensible Documentation

Would your documentation protect you if your care or actions were questioned?

This essential course will simplify the way you write and give you the skills to document in a way which is accurate, legally defensible, and improves outcomes for the people you support.

What is Defensible Documentation?

Defensible documentation is written evidence that clearly shows the care you provided, the decisions you made, and why you made them. It protects the organisation, the worker, and the person receiving support by ensuring records are factual, complete, and compliant with Standards. In aged care, disability, and mental health, defensible notes help demonstrate duty of care, reduce risk, and improve communication between team members.

Who should attend this training?

• Personal Care and Support staff
• Lifestyle staff and Volunteers
• Administration and Rostering staff
• Coordinators and Team Leaders
• Maintenance and Ancillary staff
• Anyone in aged care, disability or mental health who are responsible for writing progress notes, incident reports or case records

Training outcomes that you will achieve:

• Understand how factual objective language improves care and communication
• Know what’s relevant to document
• Learn the FACT® method, and how to use it to improve your documentation
• Practice writing clear and concise, defensible progress or case notes
• Confidently put your new skills into action to document support, change, risks, goals and progress
• Receive a Quick Reference Guide (QRG) to support ongoing documentation