Chinese Medicine & Acupuncture Society of Australia Ltd

1.  Client records – general requirements

Your client records:

comply with all Professional Standards;

are a comprehensive, true and accurate reflection of all services or goods provided;

are made at the time of providing the services or goods or as soon as practicable afterwards;

clearly identify the patient and the services or goods provided;

are written in English, understandable by a third party and in a format that allows for continuity of care; if they are maintained in another language and are requested by healthfund , they must be translated at the Recognised Provider’s expense

are at a standard that enables us to verify whether you have provided services and goods in accordance with our private health fund Recognition Criteria;

are in chronological order;

are stored in a manner that allows for prompt retrieval, and if stored in electronic format, are appropriately backed up and have a tamper- proof audit trail;

contain:

1. the patient’s name, address, date of birth, gender and contact details;
2. the Member’s consent to receive the service and the Recognised Provider must be easily identified as the treating
3. relevant medical and health history, including allergies, previous and current medication and
4. details of previous treatment and referrals;
5. presenting conditions, including symptoms;
6. baseline measures, improvements and outcomes reached; and
7. the commencement and conclusion time of each Treatment, unless you have a separate booking system that records the full name and appointment; and

unless otherwise specified under applicable laws or professional standards, the patients records are retained for a minimum of 7 years from the date the relevant service was provided and if the

client is under 21 years at the time of the Service, records need to be retained for a period of 7 years after they would have reached 21 years of age.

2. Client records – specific requirements in relation to each

Treatment

For each Treatment provided, your patient record shows:

• the date of service of Treatment;
• the provider of the service;
• the advice and instructions given;
• any referrals made and received;
• details of the type of examination performed and observations made;
• the results of diagnostic interventions or tests;
• progression of the Treatment provided by making contemporaneous
• the technique(s) used, body parts treated and methods applied; and specific details of goods supplied or herbs and vitamins dispensed or administered, including

PS : when there is a audit, some health fund request provider must make available to the fund, within 14 days of a written request from the fund, any information or documents relating to a client including receipts or invoices issued for services, Patient Records and details of any goods ordered or supplied as part of the services .

Disclaimer: This document is for information only and under any dispute please refer to private health fund client record keeping requirements on their website.