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.
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.