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 Medibank / AHM’s treatment record requirements as follows:

General requirements for treatment records:

  • Comply with all professional standards;
  • Provide a comprehensive, truthful and accurate account of all services or goods supplied;
  • Be made at the time the service or goods are provided, or as soon as possible afterwards;
  • Clearly identify the patient and the services or goods supplied;
  • Be written in English, understandable to a third party and in a format that supports continuity of care;
  • Meet standards that allow the health fund to verify whether services and goods were provided in accordance with its recognition criteria;
  • Be arranged chronologically;
  • Be stored so that they can be retrieved quickly, with appropriate backups and a tamper-evident audit trail when held electronically;
  • Include:
    • The patient’s name, address, date of birth, gender and contact details;
    • Relevant medical and health history, including allergies, past and current medications and illnesses, and details of previous treatment and referrals;
    • The presenting condition, including symptoms;
    • The condition before treatment, improvements and outcomes achieved; and
    • The start and finish time of each treatment, unless a separate booking system records the full name and appointment;
  • Be retained for at least seven years from the relevant service date, unless applicable law or professional standards specify otherwise.

Specific treatment record requirements, relating to each treatment:

  • The date of the treatment service;
  • The person who supplied the service;
  • Advice and instructions given;
  • Any referrals made and received;
  • Details of examinations performed and observations made;
  • Results of diagnostic interventions or tests;
  • Progress of treatment, documented through contemporaneous records;
  • For alternative therapies:
    • The techniques used, body areas treated and methods applied;
    • Specific details of goods, herbs and vitamins supplied, including dosage.

Source: Medibank Patient Records Standards, 26 November 2018

Related reading: Understanding Remedial Massage Treatment Records in Australia

Disclaimer: This article is for general reference only and does not provide professional advice. Its original content is protected by the author’s copyright. Neither the author nor Sunflower Software accepts responsibility for the consequences of any action taken or not taken in reliance on any part of this article.