Understanding your responsibilities
As a health provider registered with us, you have certain responsibilities when providing treatment. This includes treating our clients, privacy, rehabilitation and clinical records.
Your responsibilities as a health provider
As a health provider registered with us, you have certain responsibilities when providing treatment. This includes:
- treating clients who have an injury we cover
- providing clients with the best care
- thinking creatively about how to help clients to return to work or independence
- knowing about and following best practice
- acting in keeping with professional standards and our legislation
- complying with our policies, procedures, and your professional standards when treating and making claims for our clients
- maintaining appropriate clinical records
- providing us with reports and patient notes.
Your privacy responsibilities
If you’re working with us as a health provider, you have responsibilities when handling our clients’ information.
Protecting privacy as a supplier or provider
Our rehabilitation principles
Clients’ circumstances vary according to injury, health, work and other factors. Our rehabilitation framework makes it easier to provide the best support for each client and help them to get the best outcome possible.
The following core principles of our framework were developed around clients’ diverse rehabilitation needs:
- take a person-centred approach, understand the person, their friends, family, life roles, strengths, capabilities, and culture
- focus on the whole person and work toward improving function, activity, and participation across all areas of life
- use early interventions to give the person the best possible chance of positive outcomes
- make sure services and support are flexible enough to adapt as the person recovers or lives with permanent injuries
- be inclusive and take a multidisciplinary approach that includes the person, their friends, family, employer and others who can support the client
- focus on outcomes that help clients reach their rehabilitation goals and live a normal life.
Clinical records
Services you provide and invoice us for must be supported by clinical records that meet your professional standards and our recommendations.
Requesting your clinical records
We're legally entitled to request your clinical records. If we cover a patient’s injury, we'll provide treatment and other support if needed.
Primary care consultations receive automatic financial contributions under the Accident Compensation Regulations. However, we must check that other services such as surgery, pain management, weekly compensation and home help are related to the patient’s injuries.
What we recommend for clinical records
Your clinical records must:
- provide client identifiers such as name, date of birth and ethnicity
- provide your name, a legible signature (if on paper) and the date and time of each consultation/visit
- be written at the time of the consultation/visit or shortly afterwards and have any later records dated and countersigned
- be written in English on a permanent electronic record or, if on paper, be legible and in pen, not pencil
- record any tests or communication that influenced your diagnosis or treatment
- record any prescribed medications the patient is taking
- provide clinical reasons to justify any consultation/visit or ongoing treatment
- provide a provisional diagnosis and supporting rationale if there is a differential diagnosis
- identify a treatment plan and rehabilitation expectations, as discussed with the patient
- record any referrals made
- show consistency between your appointment record and invoice dates
- be stored securely for a minimum of 10 years after the final consultation/visit
- be transported (physically or electronically) only when essential, taking all steps necessary to protect that information.
- withstand the scrutiny of the treatment provided in the event of peer review, audit (medical or financial) or medico-legal challenge.
What to avoid in your clinical records
Make sure you don’t:
- use ambiguous abbreviations
- make offensive or humorous comments
- alter notes or disguise additions.
Handbook for providers working under the Cost of Treatment Regulations
We’ve developed a set of expectations and responsibilities to make sure we work together to provide our clients with treatment that helps them to return to work and everyday life as safely and quickly as possible.
Working together - A handbook for providers working under the Cost of Treatment Regulations