Background There is little data on the correct identification and documentation of substitute decision-makers (SDM) or ‘persons responsible’ (PR) in residential aged care facilities (RACF). Current practice may not be consistent with the Victorian Guardianship and Administration Act (GAA) 1986.

Aim To determine the extent of correct identification and documentation of SDMs or PRs as per GAA in two RACFs in Victoria, Australia.

Methods Retrospective audit of paper and scanned electronic medical records (n=88).

Admission forms, which include the resident personal details form and the medical admission were examined for identification of next-of-kin (NOK), Power of Attorney-Medical Treatment (POA-MT) or guardian. The complete medical file was then examined to confirm correct identification on the admission forms. VCAT was also contacted where confirmatory documents were not found in medical records.

Results First NOK was more consistently documented than second NOK (75% vs 33%).

POA-MT or guardianship with healthcare powers (GHCP) was noted in ∼15% of admission forms with only 15.4% having valid documents available.

In 26.1%, admission forms were unclear; of these, 34.8% were confirmed to have a POA-MT or GHCP. In 59.1%, no POA-MT or GHCP was noted; of these, 1.9% were found to have a POA-MT.

For residents with no confirmed POA-MT or GHCP, the first NOK was a potential PR (as per GAA) in 71.8%. Of these, 49% were confirmed as the PR.

Discussion/Conclusion Documentation of POA-MT or GHCP is often incomplete or incorrect. A listed NOK is not necessarily the PR. Procedures and forms that use clear, unambiguous terminology must be developed to aid correct identification and documentation of SDMs.