Commonwealth Consolidated Regulations

HEALTH INSURANCE (PROFESSIONAL SERVICES REVIEW) REGULATIONS 1999 - REG 5

                For the definition of adequate and contemporaneous records in section 81 of the Act, the standard to be met in order that a record of service rendered or initiated be adequate is that:

                (a)    the record clearly identify the name of the patient; and

               (b)    the record contain a separate entry for each attendance by the patient for a service and the date on which the service was rendered or initiated; and

                (c)    each entry provide clinical information adequate to explain the type of service rendered or initiated; and

               (d)    each entry be sufficiently comprehensible that another practitioner, relying on the record, can effectively undertake the patient’s ongoing care.