The quality and accuracy of clinical documentation in residential aged care facilities (RACFs) is a global concern, yet technology systems supporting person-centred documentation have evolved slowly. The introduction of the Strengthened Aged Care Quality Standards in 2025, requires providers to reassess how they evaluate and deliver care to enhance safety and quality. To address this, a structured digital assessment framework has been developed using agile methodology and digital co-design principles that streamlines care documentation, enabling evidence-based decision-making that optimises person-centred care while simultaneously capturing data for safety and quality assurance.

This innovation focused on delivering point-of-care documentation and decision support, was developed through a human-centred, co-design approach. Over nine months, 850+ hours of literature reviews, 150+ workshops, and extensive engagement with 23 aged care providers, universities, industry, and clinicians resulted in the creation of an assessment framework aligned with the emerging Strengthened Aged Care Quality Standards and Aged Care Act. Collaboration with nurses and clinicians was key to ensuring the framework was ‘fit for purpose,’ optimising efficiency by integrating with existing clinical workflows and adhering to safety and quality standards. The project uplifted clinical documentation standards and integrated them into existing clinical information systems to free up staff for increased resident contact, enhancing continuity of care, strengthening compliance with national standards, addressing care gaps, and improving clinician experience.

Improving nursing documentation in RACFs is essential for quality assurance, legal compliance, research, and resource allocation. Enhanced documentation can drive better clinical outcomes and elevate overall quality. The Standards have sparked collaboration between digital health organisations, clinicians, RACFs, universities, and industry. The redesign of a digital assessment framework in line with the requirements of the Aged Care Act through intensive co-design presents a unique opportunity for more effective evaluation of nursing care and resident outcomes, improving care delivery and enabling better-informed decision-making.