Australian Government - Department of Health - Office of Hearing Services
Hearing Services Program

Provider Factsheet 1 - Documentation and Record Keeping

Compliance monitoring has identified evidence of poor record keeping by contracted service providers (providers). This compromises both the continuity of client care and provider’s ability to substantiate claims. Providers will be required to reimburse any unsubstantiated claims. The information below should assist to improve record keeping compliance.

Program requirements

The Service Provider Contract 2018 – 2019 (the Contract) states that all client records are Commonwealth records. Clauses 15 & 16 of the Contract and Rule 7(3) of the Hearing Services Rules of Conduct 2012 give the Commonwealth access to program client records to allow compliance monitoring.

You must make and maintain comprehensive records for each voucher-holder who receives services. These records must be comprehensive, accurate, current, easily identifiable and accessible.

Tips to improve record keeping compliance

Please ensure

  • you and your staff understand the program requirements
  • all client notes and records are legible and have enough detail to verify the services delivered
  • all client records are kept on the client file
  • you are using the most current forms and guidance, which are available on the program website
  • information entered into the online portal matches the information on the client file.

Examples of non-compliance

  • Unreadable file notes, or evidence that records have been altered, for example changing dates or using liquid paper on claim forms and case notes.
  • Inconsistent dating in case notes, audiograms, NOAH data and other documents.
  • Incomplete, unsigned or missing forms, e.g. claim forms, WANT forms and partially subsidised device quotes.
  • Inconsistencies between client file information and details entered into the online portal, particularly 3 Frequency Average Hearing Loss (3FAHL) results and costs to client.
  • Insufficient evidence that the full services required for a claim have been completed.
  • Not retaining Practitioner Professional Body (PPB) certification for all practitioners.
  • Ambient noise/calibration certifications not being kept up to date or not to the correct standard.

 

PF1 - Documentation and Record Keeping (PDF 64 KB)

Service Provider Contract 2018-2019

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