Navigating and Updating the Client Record

July 2017

4. Quick Reference Guide

Navigating and updating the client record

The creation of a client record will reduce the number of times a person has to repeat their story. Clients will be asked to provide consent to enable their client record to be appropriately shared with assessors and service providers.

The client record contains tabs with the following information:

July 2017

· Client details

· Approvals

· Plans

· Attachments

· Services

· My Aged Care Interactions

· Notes

July 2017

1. How to access the client record

You can access the client record using the ‘Find a client’ function or from your ‘Current work’ tab, if the client has been assigned to you.

From your home page, select ‘Find a client’.

Alternatively, from within any page in the assessor portal, you can select the link to the side menu and choose the ‘Find a client’ option from the tool bar at the top right hand corner of the page.

You can undertake a basic search by entering First Name, Last Name or Aged Care User ID and selecting ‘Search’. To display more search fields, you can select Advanced Search’.

Tip: Any recently viewed clients will be displayed under the heading ‘Recently Viewed Persons’ on the ‘Find a client’ page. Selecting a client’s name will take you directly to the client record.

The ‘Find a client’ function enables assessment organisations to search for all clients registered with My Aged Care. Service providers can only search for clients who have been referred to, and accepted by, their organisation. /
‘Advanced Search’ replaces ‘Show more find options’ for a consistent search experience across all tabs that offer a card and a list view. Advanced Search options available for ‘Find a Client’ include:
· Aged Care Payment Management System (ACMPS) number
· Aged Care User ID
· Centrelink Customer Reference number (CRN)
· Client Status
· Date of Birth
· Department of Veterans’ Affairs (DVA) card number
· First name
· Home contact number
· Last name
· Locality
· Medicare Card Number
· Postcode
· Preferred name
· State
· Suburb
· System for the Payment of Aged Residential Care (SPARC) number /

Alternatively, where a client has been assigned to you, you can access the client record from the client’s expanded card view in your ‘Current work’ tab by selecting ‘View full client record’.

From list view, you can access the client record when you have expanded the client information.

A summary ‘snapshot’ of the client record is also available in PDF format by selecting the ‘View PDF of Client record’ from any tab in the client record; and includes client details, representative and carer details, notes, assessment history, care approvals, and the client’s interactions with My Aged Care. /

2. What information is in the client record?

The client record contains client information displayed across seven tabs, which are described in more detail below.

2.1 Client details

The Client Details tab contains basic demographic and contact information about the client. It is also where you can view details about the people connected to the client in the system, such as the client’s GP, carer, emergency contact, representative or other support person. In the Representatives and relationships section, you will now see the clients’ nominated primary contact person. The primary contact person can be a representative, support person or the client themselves.

The ‘Primary contact person’ can be nominated by the client or the clients’ representative. This information allows assessors, My Aged Care contact centre staff and service providers to identify the key contact person for a client. This field does not have a bearing on system generated mail correspondence the client may receive in relation to their care. /

2.2 Approvals

The Approvals tab contains a view of a client’s approvals for aged care services under the Act. This includes a client’s current approvals and approvals that existed prior to My Aged Care where the client has been associated.

Existing approvals will be displayed in My Aged Care portals once a client has been registered and successfully associated. . /

2.3 Home care

Home care information is now displayed under the ‘Home care’ section of the Approvals tab. The information displayed here may include:

Whether a client is seeking or not seeking home care services. Assessors can record or amend this by selecting ‘Edit’.
Notification of home care correspondence, particularly where a client may be considered to be vulnerable or in need of additional assistance to access care. One person from an outlet may nominate to receive notifications of any home care correspondence received by a client from the Department. This can be done by selecting ‘Edit’.

Home care package approval details for:
Pending Home Care Packages (not assigned), including:
Priority for home care services
Time spent waiting on the national queue
Interim package information
Assigned Home Care Packages, including:
Date package assigned
Take-up deadline
Status of assigned package
History of home care package

For more information about the Home Care changes in My Aged Care, see Quick Reference Guide 13 - Management of Home Care Packages from 27 February 2017, available on the Department’s website. /

2.4 Plans

The Plans tab contains any previous screening and assessment information for the client, including:

- The assessment outlet and assessor who undertook the client’s assessment

- Detailed information about a client’s assessment history

- Support Plan(s)

- Upcoming and historic review information

- Reablement and linking support history

2.5 Attachments

The ‘Attachments’ tab contains documents that have been attached to the client record, including attachments that have been uploaded using the myAssessor app. This is also where assessors can add an attachment to the client record.

‘Assessment Attachments’ are any documents that are relevant to the client’s assessment, for example, clinical notes or a discharge summary.

‘Other Attachments’ are documents that relate to the client’s general circumstances, for instance, a General Power of Attorney or Occupational Therapist drawings used in home modifications.

‘Correspondence’ are any documents

To add an attachment to a client record, follow the steps below.

Step One: Select ‘Add an attachment’

Step Two: Add the attachment by selecting ‘Browse’. Enter the required information, including name of the attachment and the type of document. Select ‘Upload’ to add it to the client record.

The document will now display in either the ‘Assessment Attachments’ tab or ‘Other Attachments’ tab, depending on the type of document attached.

2.6 Services

The ‘Services’ tab contains a record of:

· Services the client is receiving

· Services that are pending

· Previous services a client may have received.

2.7 My Aged Care interactions

The ‘My Aged Care Interactions’ tab will show the client’s history of interactions with My Aged Care.

2.8 Notes

The ‘Notes’ tab contains notes that have been created about the client. Assessors can add new notes about the client from this tab. Section 3 of this guide contain more information about the notes function.

2.9 Tasks and Notifications

All tasks and notifications relevant to the client will be displayed in this tab. Assessors will be able to see all tasks and notifications relevant to the client. Providers will only see notifications that are associated to their outlet, for clients that they are providing services to.

For more information about the Home Care changes in My Aged Care see Quick Reference Guide 9 - Tasks and Notifications available on the Department’s website. /

3. Adding and viewing client notes

My Aged Care contact centre staff, assessors and service providers can view and add different types of notes about clients through the My Aged Care portals. Assessors can also view and add these notes in the myAssessor app.

Reminder: all notes will be subject to Freedom of Information legislation. /

There are five different types of notes, listed in the table below.

Note type / Description / Examples /
Client story / A summary of the client’s current circumstances. Assessors, service providers and clients can view these notes. / Mrs Jones has just been discharged from hospital and is seeking help at home. She lives with husband and has early onset dementia.
Sensitive notes / Information of a sensitive nature about the client that needs to be available for assessment or provision of some services. A sensitive note will display a flag on the portal for the service provider against the client. They may contact the contact centre or assessor for additional information, which will only be provided to them if relevant to their service provision. This note will not be displayed to service providers or clients on system. / Mr Smith is HIV positive.
Mrs Johns has an abusive relationship with son.
Preference / Client’s stated service provision preferences. Assessors can view these notes. / Mrs Marten would prefer a Catholic provider.
Mr Dobruk is affiliated with the Croatian community.
Observations / Observations from service provider and/or assessors’ interactions with the client. Assessors and service providers can view these notes. / There is a dog on the property.
Mrs Shean seems more energetic than she did during my last visit.
Other / Additional information about the client. Assessors, service providers and clients can view these notes. / Mrs Jones has planned respite on 01/08/2017.

3.1 Who can add different note types?

· Assessors can add: Client story, Sensitive notes, Preference, Observations and Other notes

· Service providers can add: Observations and Other notes

· Clients can add: Other notes

· My Aged Care contact centre staff can add: all note types.

3.2 Who can view the different note types?

· Other and Client Story are displayed to the client, assessors and service providers

· Observations are displayed to assessors and service providers

· Preferences are displayed to assessors

· Sensitive notes are only displayed to assessors and a flag indicating the presence of the note type is displayed to providers.

· My Aged Care contact centre staff can add and view all note types.

When My Aged Care contact centre staff or assessors add a sensitive note about a client, all service providers who are sent a referral will see a flag informing them that there is a sensitive note about the client, and instruct them to call the contact centre for more information.
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3.3 How to view and add client notes

To add client notes, follow the steps below.

Step One: To add and view Client notes, navigate to the ‘Notes’ tab from the client record.

Step Two: From the Notes tabs, you can view notes about the client, and select ‘Add a note’.

Step Three: From the pop-up box, select a note type, and add a description of the note. Select ‘Save’ once complete.

A help icon in the pop up box provides information about the different types of notes to help assessors and service providers select the appropriate category. /
You cannot delete a note once saved. You can only make notes ‘Inactive’. /

To make a note inactive, select ‘Edit’ next to your note.

A pop up box will display, and you can change the status from Active to Inactive.

3.4 Adding notes in the myAssessor app

Assessors using the myAssessor app can use the notes function to record information about the client, as shown below in the ‘Notes’ section of the client details.

Client story notes will be visible on the summary of client information (card view) or in the expanded information section (list view). This information will give Team Leaders, assessors and service providers an overview of the client’s circumstances.
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For further information about the myAssessor application, see the myAssessor App - User Guide, available on the Department of Health’s website.