When used well, participant documentation both improves the quality of support clients receive and empowers them. It facilitates their active involvement — and that of their loved ones — in their support provisions. Given this, it’s no surprise that NDIS auditors want to review it. 

We recently hosted Amanda Watson, Principal Managing Partner and Founder of compliance and certification consultancy Audit Hub, in a webinar on getting your business audit ready. As an NDIS lead auditor, she’s an expert on preparing evidence ahead of audits. Here’s what she had to say about participant documentation.

Support Plans

Your support plan is one of the most important documents your team will use. It ensures participants receive consistent, high-quality care centred around their needs.

“A support plan gives the support worker and the team an understanding of who that participant is, what they like, the way they like to communicate, what the higher risk areas are that the support worker needs to know before they step foot potentially in the home,” Watson says. 

Support plans don’t stand alone, however. Watson explains that they should be the product of the strengths and needs assessment and the risk assessment. The auditors will expect to see all three documents, as well as evidence that they are regularly reviewed and updated. 

“If the auditor sees some plans that have not been touched for over 12 months, that would be raising a flag because things change for people all of the time.

She adds that it’s important to store the support plan correctly so that it is easy for support workers to find it. “It should not be embedded in your progress notes,” she says. 

Progress Notes 

Progress notes ensure that anyone reviewing a client’s support has an up-to-date understanding of the client’s progression and welfare. Additionally, if anything goes wrong, they serve as an essential record. 

“If there is an incident, it can be logged directly in your progress notes at the time of the service,” Watson explains, “and I can tell you that in terms of providing a story that supports an investigation, that is very powerful. You don't need to document all of the details but, at least in terms of an audit trail, document it right away.”

Make sure that your team knows how to write good progress notes. Watson recommends using headings, explaining that these provide a structure that allows support workers to quickly spot new information.

Consent Form

NDIS providers need to seek consent before requesting and disclosing personal information. Watson stresses that auditors will ask to see consent forms and check how early on you seek consent. 

“Please, please implement consent as early as possible,” she says. “We start on a journey with the participant very early and start collecting information… so move [the signing of the consent form] as far forward as you can.”

Although consent can be given verbally, it becomes much harder to prove that you have received it. A securely stored, signed consent form is always the best choice, both for participant empowerment and NDIS compliance. 

Service Agreement

A service agreement is a legal document that must be developed in collaboration with the client. Points it should cover include the supports provided, the dates they are provided for, costs and the dispute resolution process. The NDIS has a handy checklist targeted at clients that can help you create your agreements (scroll down to “Things to think about when making a service agreement”).

Watson recommends also including emergency procedures in the agreement. “There is now an additional requirement… to effectively identify and control emergencies,” she explains, “so you do need to develop an individualised emergency plan, and it makes sense to have that attached to that service agreement and shared with the participant.”

It’s also important to keep track of the service agreement dates. You don’t want to accidentally provide support based on an expired agreement. Ideally, your system will remind you of expiry dates with sufficient notice so that you can extend or create a new service agreement with the client, or wrap up the support you’re providing them.

You may also want to create an easy read version of the service agreement. Just because the agreement is a legal contract doesn’t mean it needs to be complex. By having an easy read document, you can ensure that the client gives their informed consent and agreement to the service. 

Some clients may not want to sign a service agreement, and that’s fine. A service agreement is mandatory, but a service agreement document is not. Watson says that if a participant doesn’t want to sign a service agreement, “you must at least still go through the service agreement process, and if [the client] doesn’t want it and they don't want to sign it, document it, and some of the reasons as to why.”

This way, you will still have documentation that you can show auditors, in addition to something to refer to while creating and reviewing support plans.

Manage Participant Documentation with the Right Systems and Tools

Participant documentation is key not just to running a quality disability support provider business but also to demonstrating you meet the NDIS quality standards. While all documentation is important, auditors will pay particularly close attention to your support plans, progress notes, consent forms and services agreements.

ShiftCare’s software takes the stress out of participant documentation. With secure storage, varying access levels, and expiry notifications, you can ensure that everyone on your team has access to the updated documents they need to do their job — whether that’s progress notes, service agreements, consent forms or support plans. 

Discover how ShiftCare can help you manage participant documentation with a free trial.