Medicare Benefits Schedule - Note GN.15.39

All practitioners who provide, or initiate, a service for which a Medicare benefit is payable, should ensure they maintain adequate and contemporaneous records. 

Note: 'Practitioner' is defined in Section 81 of the Health Insurance Act 1973 and includes: medical practitioners, dentists, optometrists, chiropractors, physiotherapists, podiatrists and osteopaths. 

Since 1 November 1999 PSR Committees determining issues of inappropriate practice have been obliged to consider if the practitioner kept adequate and contemporaneous records.  It will be up to the peer judgement of the PSR Committee to decide if a practitioner's records meet the prescribed standards. 

The standards which determine if a record is adequate and contemporaneous are prescribed in the Health Insurance (Professional Services Review) Regulations 1999. 

To be adequate, the patient or clinical record needs to:

­ clearly identify the name of the patient; and

­ contain a separate entry for each attendance by the patient for a service and the date on which the service was rendered or initiated; and

­ each entry needs to provide clinical information adequate to explain the type of service rendered or initiated; and

­ each entry needs to be sufficiently comprehensible that another practitioner, relying on the record, can effectively undertake the patient's ongoing care. 

To be contemporaneous, the patient or clinical record should be completed at the time that the service was rendered or initiated or as soon as practicable afterwards.  Records for hospital patients are usually kept by the hospital and the practitioner could rely on these records to document in‑patient care. 

The Department of Human Services (DHS) has developed an Health Practitioner Guideline to substantiate that a specific treatment was performed which is located on the DHS website. 

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