Patient reports and patient notes should be full and accurate. When a client’s ACC cover is contested, or if ACC audits your practice, the quality of your notes may be very important. We do not pay for treatment if clinical records do not demonstrate appropriate care.
Standards for notes
Your notes should:
- clearly demonstrate that you conducted each consultation with appropriate levels of skill and care
- record the main reason for the client’s visit (when the consultation involves more than one condition). If the main reason is a non-ACC covered injury or medical condition, you should not charge us for a casual enquiry about a past injury
- be legible
- be written at the time of the consultation or shortly afterwards
- have any later notes appropriately dated and signed off.
Injury information
When recording injury information please include:
- details of the accident
- how the injury happened (including its mechanism if appropriate)
- symptoms
- the injury’s clinical significance
- any relevant previous history
- clinical examination of findings
- a diagnosis and treatment plan.
Your follow-up consultation should include an assessment of the results of treatment.
Assessment of clinical notes
We often assess clinical records to make sure that:
- there is a clinical record for each treatment claimed
- the clinical record meets professional standards of documentation
- an appropriate clinical reason has been recorded to justify visits and ongoing treatment
- the treatment given is in line with current acceptable treatment numbers, frequency and quality.
Invoicing for reports and copies of clinical records
ACC occasionally asks for copies of your clinical records/notes, or for a report when making entitlement decisions.
Rates of payment
Rates of payment vary by provider group, for information on rates contact your Relationship Manager or the Provider helpline.
Please state on the invoice the actual time taken by the clinician to write the report. Time can be charged in increments of 10 minutes if it takes less than an hour to complete a report or to edit clinical notes. If you think it will take longer than an hour to prepare the report, you will need to seek prior approval from the ACC requestor.
Payment of invoices
To enable prompt payment please quote the claim number and the ACC purchase number on all invoices.
Last updated: 20 February 2009