Keeping Clinical Records
ATMS practitioners, regardless of being a provider with a health fund or not, are required to maintain full client records for each client treated. As a minimum this should include:
Keeping client/clinical records is an essential part of professional practice. Health funds also require the keeping of these records, and they form an important part in the client relationship to receive health fund rebates. All members should periodically review these requirements for Health Fund purposes, and ATMS has provided dedicated resources for members on our website, available here: Health Fund Terms & Conditions
- Client details (including full name, date of birth, gender, address and contact details including emergency contacts. For the first consultation a full case history should be taken).
- Date of each treatment.
- Nature of the illness / injury / reasons for seeking treatment.
- Detail of each treatment and/or services provided. Some health funds request the specific Acupuncture points used and methods applied, the massage techniques used and parts of the body treated and for therapeutic goods, the specific details of the prescribed herbs and/or supplements with dosage.
- Any advice or instructions given.
- Details of any referrals made.
- The outcome of previous treatment including improvements, baseline measures or outcomes reached.
- Treatment time / duration.
- Provider’s signature, initials or electronic signature.
As part of our ongoing compliance support for members, ATMS has also programmed the following webinars as part of our CPE Calendar:
Do’s and Don’ts of Clinical Practice, Betty Tannous,
7.00 pm to 8.30 pm Wednesday 3 May 2017
Clinical Case Notes for Complementary Medicine Practitioners, Keonnie Moore,
7.00 pm to 8.30 pm Wednesday 10 May 2017