Contracted Service Provider Notice
Record Keeping Requirements
(CSPN - 2015/02)
Dear Service Providers
Record keeping requirements for program clients
During audit we have been finding incomplete records or files that do not adequately document the clinical decisions made for program clients.
Contracted Service Providers (providers) are given the opportunity to supply further written information to the Office of Hearing Services (the Office) as part of the audit process however, we may initiate recovery action if the requested information cannot be provided.
Some providers have also reported that on occasions, client records transferred to them from another provider are incomplete or do not provide sufficient background information as to why clinical decisions have been reached for a program client.
I would like to remind providers of their obligations to fully document all program clients’ clinical files with all relevant client information, including evidence and reasons to support clinical decisions made.
How do I store private and program client files?
We have recently received several inquiries relating to storage requirements of private and program client files. Providers should be mindful that private client files do not need to be stored separately to program clients’ records. This previous storage requirement was removed from the current Service Provider Contract which commenced on 1 July 2012.
Where can I get further information about record keeping?
For further information on record keeping requirements, please refer to the Hearing Rehabilitation Outcomes for Voucher-Holders (Outcome 8: Confidentiality and Records), and the records provision in the Service Provider Contract 1 July 2012 - 30 June 2015. These documents are also available on the Office website at www.hearingservices.gov.au
Yours sincerely
Hearing Services Program
15 January 2015
Download this CSPN Contracted Service Provider Notice - 2015/02