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 BUPA’s treatment record requirements as follows:

You must satisfy the following clinical record-keeping requirements, together with any other requirements of your registration board, where applicable, professional body, including applicable professional standards, or the law:

(a) Clinical records must contain sufficient information about the customer’s treatment to allow another health practitioner to continue managing their care appropriately;

(b) Hard copies of clinical records containing sensitive or personal information must be kept in a secure, lockable, fire-resistant storage cabinet or area when not in use. Such records must not be stored or left in public areas;

(c) Digital copies of clinical records containing sensitive or personal information must be kept in an environment and electronic system accessible only to you and authorised people who need access. The electronic system:

(i) May be audited by Bupa where permitted under the terms;

(ii) Must be protected by current industry-standard user authentication, including usernames and passwords, firewalls and antivirus technology; and

(iii) Must be backed up regularly and securely;

(d) You must create and retain a clinical record for every good or service supplied to one of our customers;

(e) Records relating to an individual customer must be kept together. Each entry must be made in chronological order and allow an audit trail for any changes;

(f) Each customer’s records must be accurate, clear, concise, legible to a third party, written in English and clearly identifiable as relating to that customer;

(g) Clinical records must be readily retrievable when required;

(h) Changes or corrections to an original clinical record must not erase the original information;

(i) You must not delegate responsibility for the accuracy of clinical records you create or retain about a customer;

(j) Clinical records must be individualised for each customer. Where pre-filled notes, templates or copy-and-paste methods are used, they must be edited immediately to reflect the individual patient’s treatment plan;

(k) You must retain each customer’s relevant medical and health history, including details of the presenting condition, signs and symptoms. This history may include, but is not limited to:

(i) Previous illnesses;

(ii) Pregnancy status;

(iii) Allergies;

(iv) Current medications;

(v) Details relevant to the presenting condition; and

(vi) Presenting signs and symptoms.

(l) Each customer visit and the goods or services supplied must be recorded separately. Each record must include, but is not limited to:

(i) The date of treatment;

(ii) Treatment details, including:

• The treatment plan;

• The name of every person providing treatment;

• The body area, tooth identification or body part treated;

• The treatment techniques used;

• Any herbs or vitamins supplied or prescribed, including dosage;

• Any medicines or drugs administered or prescribed, including dosage;

• Any materials used or applied; and

• Any advice or instructions given;

(iii) Referral details;

(iv) Acceptance of the treatment plan and consent;

(v) Informed consent to treatment provided to the customer;

(vi) Consent from a parent or legal guardian for treatment provided to a child or minor;

(vii) The outcome of any previous treatment; and

(viii) Any further details recommended by your professional body, registration board, where applicable, or both; and

(ix) Effective from 1 February 2021.

(m) General descriptions or information about a prescribed course, such as product information, must not be submitted and will not be accepted as evidence that goods or services were provided.

Source: BUPA, Our Ancillary Provider Terms, 1 February 2021

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.