HCF Treatment Record Requirements

As the complementary therapy industry expanded rapidly, health insurers introduced stricter requirements. The original article describes traditional paper records as no longer sufficient and digital treatment record management as a basic part of industry practice.

The original article sets out HCF’s treatment record requirements as follows:

8.1 A recognised provider must keep accurate and understandable treatment records for each extras service supplied to a member, at the time of service or as soon as practicable afterwards. Records must include:

(a) The member’s details, including full name, date of birth, gender, address and contact details;

(b) The date and time of each extras service and all procedures performed;

(d) The nature of the member’s illness or condition, their symptoms and the reason for seeking the extras service;

(e) Any improvements achieved, the condition before treatment and the outcome;

(f) The member’s relevant medical or health history and the nature of any health management plan;

(g) The member’s consent to receive the extras service;

(h) The recognised provider must be clearly identifiable as the treating practitioner.

8.2 Recognised providers must retain diagnostic instruments, records and models relating to extras services provided to members, including X-rays, scans, photographs, plaster casts and study models. If a provider supplies goods specially made or customised for a member, copies of related orders and supplier invoices must be retained, including for dentures, crowns, bridges, custom orthotics and optical lenses.

8.3 Treatment records must be retained for the minimum period required by legislation relevant to the profession. Where no such legislation applies, records must be kept for at least seven years. If the member was under 21 when the extras service was provided, records must be kept for seven years after the member turns 21.

8.4 Recognised providers must back up electronic treatment records regularly and keep a copy securely away from the business premises.

8.5 Patient records must be kept in English. If they are kept in another language and HCF requests a translation, the recognised provider must arrange it at their own expense.

8.6 Recognised providers must ensure treatment records can be retrieved promptly when requested by HCF.

Source: TERMS AND CONDITIONS FOR HCF RECOGNISED PROVIDERS OF EXTRAS SERVICES

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