Clinical Reporting and Assessment Standards

Clear and timely clinical reporting is essential for continuity of care, regulatory compliance, and accountability. Suncare requires all Associated Providers who deliver clinical services or make recommendations to adhere to specific reporting standards.

Reporting Format:

• SOTAP format: All clinical reports must be prepared using the SOTAP structure—Subjective, Objective, Treatment, Assessment, Plan. This ensures consistency and clarity in documentation.
• SMARTA goals: Document all goals using the SMARTA framework (Specific, Measurable, Achievable, Relevant, Time-bound, Agreed).
• Submission timeframe: Submit clinical reports to the allocated Care Partner no later than three business days after the service.

Standardised Assessment Tools:
Use evidence-based outcome measures consistently across reports. At a minimum, apply the following tools where relevant:

• Cognition: Montreal Cognitive Assessment (MoCA)
• Falls Risk: Falls Risk for Older People (FROP-COM)
• Mobility & Balance: Timed Up and Go Test (TUG)
• Functional Capacity: Barthel Index or Functional Independence Measure (FIM)
• Pain: Numerical Rating Scale (NRS) or Visual Analogue Scale (VAS)
• Mood/Wellbeing: Geriatric Depression Scale (GDS)
• Nutrition: Mini Nutritional Assessment (MNA)

Additional outcome measures may be required depending on the clinical discipline and the customer’s needs.

Recommendations:
When recommending equipment, therapy, or additional services, clearly justify your recommendations, link them to assessed needs, and align them with the customer’s care goals.

By maintaining high standards in clinical reporting and assessment, you help ensure that every customer receives the best possible care and that Suncare can monitor and improve service quality.