Open Disclosure in Aged Care: Documenting Incident Communication and Follow-Up

Open Disclosure Is a Process, Not a Single Conversation

After an incident or unexpected outcome, the person receiving care should be supported to understand what is known, what is not yet known, what has been done for immediate safety, and what will happen next. Documentation connects the initial acknowledgement with later updates, review findings, support, and improvement actions.

The approach should be proportionate to the event and guided by the resident's communication, decision-making, cultural, emotional, and advocacy preferences.

Keep Related Processes Connected but Distinct

An open disclosure note does not replace the clinical record, incident report, investigation, complaint record, insurance notification, or regulatory assessment. Cross-reference the relevant records without copying unnecessary sensitive detail. The guide to SIRS incident documentation explains how reportability assessment and response records can be linked.

Record the Person's Communication Preferences

Ask the resident how they want information provided, who they want involved, whether they need an interpreter or advocate, and when they would prefer further contact. Do not assume family involvement is authorised. If a representative or substitute decision-maker is involved, document their role and the basis for information sharing.

Capture the Initial Communication Carefully

Record who participated, the date and method, the facts explained, acknowledgement or apology offered, immediate actions, questions asked, support requested, information not yet available, and the next contact point. Attribute statements to the speaker and avoid speculation, blame, premature findings, or promises about an outcome.

Open Disclosure Documentation Checklist

• Confirm immediate care and safety actions are recorded in the appropriate clinical record.
• Identify the resident's preferred contact method, participants, and accessibility support.
• State the known facts in clear, non-technical language.
• Record questions, concerns, and the person's own account.
• Identify what remains under review.
• Name the contact person and agreed next update or trigger.
• Track promised support and practical actions to completion.
• Link incident, complaint, investigation, and follow-up records where relevant.

Example Communication Record

"At 2:30 PM, manager Lee met with George and, at George's request, his daughter Maya by video call. Lee explained that George had received another resident's labelled laundry bag and that staff had recovered both bags. Lee acknowledged the distress and apologised for the mix-up. George said he was worried his personal items had been seen by others and asked how labelling would change. Lee explained that the cause was still being reviewed and did not make a finding. George requested a phone update after the review and asked that future meetings include Maya. Next update assigned to Lee following the internal review."

Document Follow-Up Until Actions Are Closed

Later entries should show new verified information, answers to questions, the resident's response, support provided, investigation outcomes that can be shared, improvement actions, and whether commitments were completed. If the resident disagrees with the outcome, document their perspective and available complaint or review pathways respectfully.

Use the family communication documentation guide to keep contacts purposeful, authorised, and traceable.

Learn Without Turning the Record Into a Defence

Open disclosure documentation should demonstrate honest communication and follow-through, not manufacture certainty or minimise impact. Review whether updates occurred as agreed, accessible supports worked, concerns reached the right governance process, and corrective actions were checked. The broader aged care incident-reporting guide can help teams connect immediate facts with investigation and learning.

This article is for general documentation education. Follow current open disclosure guidance, privacy duties, incident requirements, resident preferences, and organisational procedures.