NDIS Policies and Procedures Manual – Core Module
Document Number: CM-POL-022
Document Control
This table shows a record of significant changes to the document.
| Legal Name: | Holistic Healthcare Management Services |
| ABN: | 20695058096 |
| ACN: | 695058096 |
| Primary address/head office: | 15 Agasse Way, Tapping WA 6065 |
| Document Name: | NDIS Policies and Procedures Manual – Core Module |
| Document Number: | CM-POL-022 |
| Approved by: | Director |
| Date Approved: | February 2026 |
| Version No: | 1.0 |
| Comments: | Initial Release of the Policies and Procedures Manual |
| Next Review Date: | May 2026 |
Introduction and Purpose
Holistic Healthcare Management Services is committed to safe, effective, and participant-centred medication management. This policy outlines how medication is handled, stored, administered, recorded, and reviewed to ensure compliance with the NDIS Quality and Safeguarding Framework, relevant legislation, and best-practice standards.
This policy ensures participants receive their prescribed medications safely and correctly; workers are competent and trained in medication administration and management; medication records are accurate, updated, and securely maintained; and incidents and medication errors are identified, reported, and reviewed for continuous improvement.
Scope
This policy applies to all workers involved in the administration, handling, or monitoring of medication for participants. It encompasses procedures for administration of medication, storage and secure handling of medication, monitoring and managing medication effects and side effects, incident prevention, reporting and resolution related to medication errors, and training, competency, and ongoing evaluation of workers involved in medication management.
Definition
| Term | Description |
|---|---|
| Medication | Any prescribed or over-the-counter drug, supplement, or remedy used to support participant health. |
| Medication Administration Record (MAR) | A document used to record details of medication administered to participants. |
| Adverse Reaction | An undesired or harmful response to medication. |
| Medication Error | Any deviation from the prescribed medication plan, including incorrect dosage, timing, or participant. |
| Self-Administration | When a participant independently manages and takes their own medication. |
| PRN Medication | Medication taken “as needed” rather than on a set schedule. |
| Dose Administration Aid (DAA) | A pre-packed system that organises individual medication doses. |
| Chemical Restraint | A medication used to influence a participant’s behaviour, only permitted with proper authorisation. |
Outcomes and Indicators
| Term | Description |
|---|---|
| Each participant requiring medication is confident their provider administers, stores and monitors the effects of their medication and works to prevent errors or incidents. |
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Guiding Principles
- Participant Safety First: Medication management processes prioritise participant safety and wellbeing.
- Compliance with Standards: Adherence to NDIS Practice Standards, regulatory requirements, and evidence-based best practices.
- Transparency and Accountability: Clear documentation, open communication, and regular auditing to prevent errors and ensure compliance.
- Empowerment: Participants are informed and involved in their medication plans wherever possible.
Policy
Accurate Medication Records
Holistic Healthcare Management Services will ensure that medication records for each participant include detailed information on the medication name, dosage, administration schedule, and route of administration (Indicator 1); specific details for identifying the participant, including photograph and identifiers; and comprehensive instructions for administration including special handling or storage. All records will be securely stored and regularly reviewed.
Worker Competency and Knowledge
All workers responsible for administering medication will be appropriately trained and hold relevant qualifications; demonstrate a thorough understanding of each participant’s prescribed medications, potential side effects, and actions to take in case of adverse reactions or incidents (Indicator 2); and participate in regular refresher training.
Secure Storage of Medication
Medication will be stored in a safe, secure environment meeting requirements such as designated lockable and temperature-controlled storage areas; separation of medications to prevent errors with clear labelling (Indicator 3); and restricted access to authorised personnel only.
Communication and Training on Emergency Protocols
A proactive approach will be taken to prevent medication errors, including clear communication during handovers between shifts, implementation of double-check systems for high-risk medications, and immediate documentation and investigation of any medication errors or adverse reactions.
Procedure
Maintaining Accurate Medication Records
Accurate medication records are maintained through initial record creation obtaining a thorough medication history and collaborating with healthcare providers, ongoing updates when prescriptions or health status change, and weekly reviews crossing-check MAR entries with physical stock.
Administering Medication
Medication administration follows strict protocols involving preparation by verifying MAR and participant ID; adhering to the Six Rights of Medication Administration (Right Participant, Right Medication, Right Dose, Right Route, Right Time, Right Documentation); and post-administration monitoring to observe side effects or adverse reactions.
Managing Medication Effects and Side Effects
Monitoring therapeutic effects and recording side effects in detail guides support plan adjustments. In the event of an incident, workers will provide first aid, inform supervisors and healthcare providers, document details in the incident management system, and conduct post-incident reviews.
Secure Storage of Medication
Medication storage prioritizes security through lockable cabinets or temperature-controlled units, restricted access logs for authorized personnel, and regular inventory audits to dispose of expired or unused medications safely.
Worker Training and Competency
Training involves initial structured programs covering administration techniques and emergency protocols with practical assessments, as well as annual refresher training and competency evaluations.
Forms of Medication Management
Holistic Healthcare Management Services implements a structured approach covering assisting participants with self-administration; direct administration by qualified workers following the 8 Rights; managing PRN and high-risk medications with dual-worker verification; handling medication refusal and escalation; safe storage and disposal; processing phone orders securely; and managing chemical restraints strictly in accordance with NDIS guidelines and formal Behaviour Support Plans.
Roles and Responsibilities
| Ref No | Roles | Responsibilities |
|---|---|---|
| 1 | Board and Senior Management |
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| 2 | Workers |
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| 3 | Participants and Support Networks |
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Record Keeping
- Medication Administration Records (MAR): Maintain detailed logs of all medication administration activities, including date, time, dosage, and worker initials.
- Incident Reports: Document all medication-related incidents, including errors, adverse reactions, investigation findings, and corrective actions.
- Training Records: Store documentation of worker training sessions, attendance, and competency evaluations.
- Storage Audits: Maintain records of regular audits of medication storage areas, including inventory checks and disposal logs.
Related Documents
- Medication Administration Record
- Medication Management Consent Form
- Administration of Medication Evaluation Checklist
- Self-Assessment of Medication (SAM) Assessment Tool
- Staff Handbook
- Incident Report Form
- Incident Investigation Form
- Incident Register
References
- NDIS Quality and Safeguards Commission Standards
- NDIS Practice Standards
- Relevant State and Federal Legislation on Medication Management
Policy Review
This policy will be reviewed annually or in response to changes in regulatory requirements, participant needs, or organisational circumstances. Feedback from workers and participants will inform updates to ensure continued relevance and effectiveness.
