On this page
- Top 10 administrative record keeping tips
- Administrative record keeping checklist
- Electronic administrative record keeping checklist
- Fraud prevention
- Further record keeping information
- Support tools
DisclaimerThe material contained in this Administrative Record Keeping Guidelines is provided as a general reference for health professionals only and on the understanding that the Department of Health (the Department) is not providing an endorsement of the material or providing professional advice.
Before relying on the material contained in these guidelines, health professionals should obtain appropriate independent professional advice relevant to their circumstances to evaluate the material’s accuracy, currency, completeness and relevance for their purpose.
ForewordWe are pleased to present the Department’s Administrative Record Keeping Guidelines.
We aim to provide helpful tools and information that are high quality and easy to use, so it is beneficial for you, your patients, your staff and your practice.
The Administrative Record Keeping Guidelines provides useful information and tools that may support good administrative record keeping within your practice.
The Administrative Record Keeping Guidelines are presented as an addition to the many resources you may already use for your record keeping guidance. This allows you to make decisions and choose areas of the guidelines that can be tailored to your practice needs.
We recognise practice managers play an important role in the administration of Australia’s health system. The guidelines have been developed, using a collaborative and co-design approach, by the Australian Government and the Australian Association of Practice Managers, general practitioners and other health professionals. The guidelines provide support that is easy to understand and will assist practice managers and health professionals.
These guidelines contain information on good record keeping practice, including electronic records, in recognition of the increasing number of practices operating as ‘paperless’. The guidelines also provides information on preventing and reporting fraud, staffing considerations and other useful services provided by the Department.
In addition, these guidelines can be found on the Department’s website in a printable version.
We will continue to work closely with practice managers and health professionals to support good administrative record keeping.
IntroductionEffective record keeping benefits all medical practices. It improves the efficient day-to-day operation of your practice; helps record and maintain your patient information and enables transparent reporting.
There are other benefits related to effective record keeping. These include maintaining the security of confidential clinical files, supporting staff to do their work more effectively, improving staff retention, and enhanced business continuity.
Having adequate administrative records may also assist if you are ever asked to participate in an Australian Taxation audit, health provider compliance audit or for accreditation purposes. It is important to understand that record keeping obligations differ depending on the purpose of the records. You may also not be aware that neglecting record maintenance may increase the risk of receiving an incorrect Medicare payment or mean that you are not able to provide adequate evidence to substantiate claims.
Administrative Record Keeping Guidelines have been designed to provide you with a range of helpful suggestions, general information and guidance to assist you to implement and maintain adequate record keeping systems that you may find beneficial for your practice.
The guidelines contain:
- effective hard copy and electronic administrative record keeping suggestions
- record keeping checklists
- case studies on non-compliance and fraudulent activities that were due to inadequate administrative record keeping
- information on how to report suspected fraud, and
- staffing considerations in relation to administrative record keeping.
Top 10 administrative record keeping tipsBelow are 10 simple tips that may be beneficial in establishing and maintaining an effective administrative record keeping system. The benefits of maintaining accurate, reliable and useable records can help to increase the efficiency and effectiveness of the practice business. It will ensure your practice is able to access information when required and meet all accountability and compliance business requirements.
Establish what processes are needed for administrative records to be effectively maintained and how this will be achieved. Planning an administrative record keeping process will help you maintain a record keeping system that works for your practice and provides clear expectations for practice staff.
To make it easier for practice staff to do their job, have information collected and stored in a consistent way within your practice; all staff should follow the same policies and procedures.
Have all your staff made aware of, and ensure they understand, administrative record keeping policies and procedures. By communicating expectations clearly, you will benefit from consistent administrative record keeping standards within the practice.
Know the capabilities of your software and provide appropriate training to staff. Most software used in practices today has capabilities that will make it easier for you to keep accurate administrative records. Training your staff in record keeping will benefit your practice by increasing the reliability and consistency of your practice and patient records. This will also reduce staff frustration when records cannot be located quickly and easily.
5. Allocate appropriate resources
Allocate the appropriate resources needed to maintain your records, for example, staff and physical resources. By doing this, you will be able to better manage your administrative records effectively, leaving staff feeling supported and more positive about their position. You may choose to make the Administrative Record Keeping Guidelines a part of the range of record keeping guidance tools that you have available for staff in your practice.
Don’t be afraid to modify your record keeping system if you find a more efficient way to achieve results. Regular reviews of your record keeping systems will keep them up-to-date and operating in a way that is beneficial to the practice.
7. Embrace technology
Regularly investigate if new technology is available that may help improve the efficiency of your administrative record keeping system. Practice staff will appreciate any efforts made to improve the task of keeping records, giving them additional job satisfaction.
Nominate your practice champion—delegate responsibility for monitoring administrative record keeping practices to a staff member who will enjoy the challenge, accept responsibility and remain accountable. Having a nominated champion will enable staff to remain focused on your record keeping policies and procedures and identify where improvements could be made.
Know your responsibilities—what to record, how to maintain records and how long they should be kept. You should also consider your obligations if asked to participate in a health provider compliance audit. Having accurate and reliable records during an audit will allow you to easily confirm that the Medicare payments you received for services were correct.
Encourage staff to provide feedback on how the record keeping system is working and how it could be improved. In doing this, you may gain valuable suggestions that will bring continuous improvement to your administrative records, improving the efficiencies of the practice.
Administrative record keeping checklistFor good administrative record keeping it is important to have the right people, resources, policies and procedures in place. This can put your practice in the best possible position to access your business records to make informed decisions that will benefit the practice.
The following administrative record keeping checklist can help you evaluate and review how your administrative records are being managed and whether there are any areas for improvement. Ongoing continuous improvement can make your administrative record keeping practices more effective for your practice needs.
Although not designed to be a checklist to assist directly with a health provider compliance audit, it may be a valuable tool to prepare your records in case you are ever asked to participate in a health provider compliance audit.
Below each question in the checklist is a description of common characteristics of good administrative record keeping. When considering whether to answer yes or no for each question, refer to the description to assess your practice’s current administrative record keeping processes. It will also give you advice on how you might be able to improve record keeping in your practice.
Question 1: Does your practice have an administrative record keeping policy?
- Yes or No
- written down and accessible to all staff
- descriptive about the responsibilities that all staff have for managing records—this might include, but is not limited to, Medicare records
- inclusive of email and other electronic records, and
- descriptive of possible outcomes for incorrect claiming of Medicare services or Medicare fraud.
Administrative record keeping policy
Ensuring your practice has an administrative record keeping policy in place enables staff to access information your practice requires easily, supports the operations of the practice and assists with meeting any compliance requirements.
Question 2: Does your management support good administrative record keeping practices?
- Yes or No
- informing all staff that record keeping is a priority—this might be achieved by incorporating record keeping practice standards into your practice manual or leading by example
- providing a budget for record keeping tools
- ensuring breaches of record keeping policy are investigated and taken seriously, and
- reporting all suspected fraud.
You could also educate staff on the seriousness of Medicare fraud and how they should report it. Staff need to be aware that this can occur in any practice environment, for anybody who has access to claiming services and their associated records. If management is approachable and provides understanding to their staff this can potentially protect the practice from exposure to fraudulent activity.
For information on how to identify if fraud is potentially occurring in your practice, see the fraud prevention section of these guidelines or go to humanservices.gov.au/hpcompliance
Question 3: Is the responsibility and accountability for administrative record keeping assigned to a specific person or group of people?
- Yes or No
- Managing all your practice’s records
- ensuring the day-to-day record keeping processes are happening daily
- completing regular checks to ensure policies and procedures are being followed, and
- conducting a review process to check all records for accuracy.
Question 4: Have staff who manage records been trained in administrative record keeping?
- Yes or No
- helps them identify what types of information should make up an administrative record
- helps them understand universal record management standards, such as file registration, record movements, record handling, confidentiality and record disposal
- gives them information about the potential risks associated with making an incorrect Medicare claim and the potential for fraud
- ensures staff are aware of their responsibilities in relation to administrative record keeping, and understand the importance of what they write, how they handle and how they alter a record, and
- occurs regularly and is flexible in terms of content.
Question 5: Does your practice have procedures for handling and managing administrative records?
- Yes or No
- written down
- in accordance with your record keeping policies
- clear accessible to all staff, and
- clearly state who is responsible for work relating to record keeping procedures.
Consider the use of forms or checklists to help staff when completing record keeping tasks as this will make it quick and easy for them to complete, making it more likely to occur on a daily basis. Include information about how to manage information related to Medicare claiming, this may then reduce the possibility of incorrect Medicare claiming.
Question 6: Do your staff know the administrative record keeping obligations for your practice?
- Yes or No
- know and adhere to the laws, obligations and policies that apply to your practice
- keep documentation of actions and decisions
- remain up-to-date with changes to laws, obligations and policies, and
- have methods in place to make sure updates are incorporated into your policies and procedures.
Consider doing an analysis of all your record keeping obligations for relevant bodies. This could help you identify any gaps in your understanding of record keeping requirements, reducing the confusion that may arise if staff are unsure. A simple suggestion is to develop a list of relevant guidelines, laws and obligations, including where they can be accessed for additional information. You should also consider a review date schedule to help in keeping this information up-to-date. Combined, these suggestions could help prevent your practice being unprepared, caught unaware or inadvertently not meeting your record keeping obligations.
Question 7: Can your practice’s administrative records be found easily when needed?
- Yes or No
- a file movement register so you know where files are at all times
- a system in place to ensure records are stored securely
- labelling and numbering conventions for files that all staff understand, and
- an archived record system that is clearly defined and allows staff to find archived records easily.
Record keeping obligations
In order for staff to meet and understand practice record keeping obligations, it is important they are educated and kept well informed about the management of records. Practice staff will then understand what is required of them and ensure records are appropriately managed and maintained.
Question 8: Are the administrative records in your practice stored securely so that they can’t be stolen, damaged or altered?
- Yes or No
- keeps all records (not just clinical records) secure
- ensures that only the appropriate staff have access to these records
- keeps records, storage areas clean and clear of clutter
- makes sure staff understand policies on storage, damage and alteration of records and take the appropriate action if a breach occurs
- checks records regularly for unauthorised alteration or deliberate damage
- makes sure all staff are aware of the consequences of fraud
- makes sure all staff are aware that records are checked for accuracy and all suspected cases of Medicare fraud are reported
- has a disaster recovery plan in place, in case of the loss or destruction of
- makes sure all electronic records are backed-up and that the integrity of the back-up data is also checked.
To improve administrative record keeping consider reviewing the security of your records regularly and talking to your staff about any doubt about their commitment to security and confidentiality of practice records. It is an advantage to keep a log of privacy breaches so that improvements can be made to the practice’s record keeping processes and procedures if required. It is important to be realistic about the vulnerability of your records so that ongoing improvements can be made if necessary.
Administrative record security
It is important to monitor security and access of patient records and update record security procedures on a regular basis. Undertaking a review of these processes can assist in identifying the types of requirements your practice has concerning records access and security.
Question 9: Does your practice adhere to regulations governing the destruction of administrative records?
- Yes or No
- know the laws governing the destruction of personal and confidential information
- use appropriate disposal methods such as security bins and shred sensitive records if deemed suitable for destruction
- have clear written procedures for the disposal of records included in policies, and
- have a written disposal schedule.
Regularly reviewing your processes
Regularly reviewing your administrative record keeping processes will improve records management within your practice. It is an advantage to encourage staff to participate in reviews as they will gain more understanding about the policy and procedures and improve standards of record keeping within the practice.
Question 10: Does your practice conduct both staff performance reviews and internal audits of your administrative record keeping processes? Do you report on the outcomes of the audits and do you make improvements based on the findings?
- Yes or No
- uses record keeping performance indicators as part of your staff performance reviews, so staff know what is expected of them
- has a process for reporting and presenting the outcomes of internal audits to staff, where appropriate
- ensures internal audit findings are used to improve administrative record keeping standards within your practice, and
- uses internal audit findings to set future record keeping goals for your practice.
It can be very difficult to change long standing, entrenched administrative record keeping methods. Scheduling staff to participate in regular reviews of the procedures will help them understand your policies and procedures and see areas for improvement. This way the staff will be prepared to embrace changes to records management processes.
Electronic administrative record keeping checklistBusinesses are more reliant on electronic solutions for daily functions, and your practice may already keep administrative records electronically or be entirely paperless.
Storing administrative records electronically can require special consideration. Electronic records can be altered or lost and preventing this from occurring will benefit your practice with accurate records that are easily retrieved increasing the efficiencies in your practice.
The following electronic administrative record keeping checklist can help you evaluate and review how your electronic administrative records are being managed and whether there are any areas for improvement. It may also assist if you need to participate in a health provider compliance audit.
Below each question in the checklist there is a description of common characteristics of good electronic administrative record keeping. When considering whether to answer yes or no for each question, refer to the description to assess your practice’s current electronic record keeping guidelines, and for advice on how you might be able to improve administrative record keeping in your practice.
Question 1: Does your practice have a computer security coordinator?
- Yes or No
- a person/group of people specifically responsible for managing the security of your electronic records
- a written job description relating to the role(s)
- provides staff with training about computer security, and
- conducts regular reviews of the role and staff performance in the role.
Question 2: Does your practice have an electronic administrative record security policy?
- Yes or No
- has a written policy available to all staff
- reviews the policy regularly, and
- trains staff about security of electronic administrative records.
Question 3: Does your practice have written procedures on naming protocols for data that is filed electronically?
- Yes or No
- ensures staff know about the procedures and where to find them, and
- trains staff about the procedures and naming protocols.
Question 4: Do you have policies that define different access levels for your electronic records?
- Yes or No
- has a written policy on the levels of access that exist for the various roles within your practice
- has policies that outline how unauthorised access will be managed
- gives staff an individual password that they must use at all times
- changes staff passwords regularly
- ensures passwords are not shared and are kept secure, and
- ensures access to files is checked by using the audit capabilities of your
Question 5: Do you have a disaster recovery plan for your computer system?
- Yes or No
- uses a tested disaster recovery plan
- has an uninterruptible power supply
- has procedures in place to maintain records if the computer system is down, and
- has a schedule for regularly reviewing and updating the disaster recovery plan.
Question 6: Do you back-up all your data on a daily basis and do you store your back-up data off site?
- Yes or No
- backs-up its computer system each day
- stores all back-up data off site
- regularly checks that the backed-up data is not corrupt
- tests the back-up system regularly
- has staff who are specifically responsible for backing-up data, and
- has a written procedure for backing-up data daily.
To make it easier for the staff in your practice, you could use a data management company to back-up and store your data by networking your computer(s). You could also consider taking back-up data away from the practice to a secure site at the end of each day. This will ensure the data is stored safely and securely and can be retrieved if you are required to reboot your system(s) and will allow for the continuation of practice business.
Having a disaster recovery plan in place will make it easier for your practice to retrieve the most current updates of patient records and allows for the continuation of business during and after a disaster.
Question 7: Do you have anti-virus software installed on your computers?
- Yes or No
- has anti-virus software installed on all computers
- keeps your anti-virus software current, and
- trains staff about how to use the anti-virus software and their responsibilities for ensuring it works effectively.
To improve electronic record keeping, remember that if your practice staff are using the internet, your computer system may be exposed to viruses that could destroy or corrupt your files and computers.
It is advantageous for staff to know about your anti-virus software and know how to make sure it is working properly because your practice can then benefit from electronic records that remain uncorrupted. It is also an advantage to regularly upgrade your software because new viruses are emerging all the time. If you are unsure about your virus protection, consider getting a computer expert to check your system to ensure it is covered from the potential threat of viruses, that way your practice records can be easily relied upon for accuracy.
The importance of storing your back-up data off site
Storing practice back-up data in a safe and secure location off site will ensure practice staff are able to recover patient records and their most current records if your practice location is compromised. This can protect patient records and allow for the continuation of daily practice business which is a benefit to patients and staff.
Question 8: Do you have hardware and/or software firewalls installed?
- Yes or No
- has firewalls installed on all computers, and
- tests the firewalls regularly.
Question 9: Is your computer system maintained at a high performance level, and do your staff deal with and report computer performance issues promptly?
- Yes or No
- has a staff member that is specifically responsible for testing and maintaining computer systems
- tests your computer systems regularly
- has an easy to follow system for reporting computer issues
- makes sure all staff are trained and know how to report computer issues, and
- has access to expert computer support.
Question 10: Are all staff trained in your practice’s computer system functions, and do they know about your practice’s policies and procedures for electronic record keeping?
- Yes or No
- has policies and procedures accessible to staff
- ensures staff are confident handling all forms of electronic records and storing them according to policies and procedures, and
- regularly reviews policies and procedures and gives staff the opportunity to
It is an advantage if records are labelled and information systems are indexed correctly, enabling staff to retrieve accurate records in a short period of time, increasing efficiency within the practice.
Fraud preventionThe Department knows that most people want to do the right thing when it comes to compliance. However, there are a small number of people who do engage in fraudulent and illegal behaviour. These guidelines can help you prevent Medicare fraud occurring in your practice.
If during an audit we determine that an incorrect payment was made, the health professional will be asked to repay any benefit that should not have been received and the penalties that may apply.
In cases of inappropriate practice, we will refer the matter to the Director of the Professional Services Review (PSR) for professional peer review.
The PSR is an independent statutory body responsible for making decisions about inappropriate practice. The PSR is accountable to the Minister for Health.
If potentially fraudulent activities are identified, we have an obligation to respond to this behaviour according to the law, and where appropriate, will refer matters to the Commonwealth Director of Public Prosecutions for consideration of criminal prosecution.
If you suspect fraud at your practice you can report it anonymously in the following ways:
Call Australian Government Services Fraud Tip-Off Line 131 524 (call charges apply).
Online humanservices.gov.au/hpcompliance then Information on health provider compliance audits, including details on records that can be used to substantiate services, is available at humanservices.gov.au/hpcompliance
Further record keeping informationThe following information can help you support your team to maintain appropriate records.
Your administrative record keeping processes could be included in your practice manual to highlight their importance to staff.
You could consider including information on:
- how non-compliance may occur without accurate administrative record keeping
- staff roles and responsibilities
- managing Medicare payments
- privacy, confidentiality and security issues
- allocation of appropriate passwords and permissions
- computer security system procedures for virus management
- procedures for backing-up electronic information
- record keeping obligations, and
TrainingStaff need to be trained in, and feel confident about administrative record keeping. Ongoing education and training will help make sure staff have the skills and competencies needed to follow your record keeping processes correctly.
Staff will see the benefit of training as their knowledge and awareness increases, which will often lead to increased job satisfaction. Training can also help staff easily adapt to new technologies.
You could consider:
- having a staff training plan
- training all administrative staff
- having a system for identifying training topics and their order of priority
- using staff performance reviews to identify training needs
- keeping records of staff training to make sure all staff have participated in training
- establishing a staff induction program and ensuring administrative record keeping training is an integral part of the program
- monitoring new staff to make sure they are aware of their responsibilities, for example, with a mentor or ‘buddy’ system
- assessments for staff before they work unassisted, and
- sponsoring staff to complete formal qualifications (see the courses on practice management and medical reception section of these guidelines).
InductionYou might consider developing an induction checklist for new staff that includes the following topics.
- Practice administration
- How to handle incoming and outgoing correspondence
- Details about practice consultation fees
- Managing Medicare payments
- Administrative record keeping obligations
- Patient records and confidentiality
- Privacy, confidentiality and security of patient information
- Handling clinical information
- Archiving and retention of records
- Transferring patient records
- Practice security policies, for example about the storage of prescription pads, stationery and patient accounts
- Computer administration
- Allocating appropriate passwords and permissions
- Locking computers and activating screen savers
- Computer security procedures
- Procedures for computer virus management
- Procedures for backing-up electronic information
- Human resource management
- Staff code of conduct
- How to report fraud
- Requirements for continuing professional development
The role of management in supporting staff in effective administrative record keeping
Staff should be provided with the support and resources they need to do their job effectively. You could consider:
- developing clear policies and procedures providing staff with opportunities to network with peak bodies and other medical practices so they can share ideas about administrative record keeping
- involving staff in monitoring and improving administrative record keeping systems so they feel accountable for the systems
- providing clear lines of accountability and responsibility
- including record keeping responsibilities in job descriptions, including clear expectations, and
- having a staff code of conduct that includes expected behaviours and legal responsibilities.
Support toolsThe following are a range of tools that are designed to assist you and your practice when claiming Medicare benefits.
Health professional guidelines
A range of health professional guidelines have been produced after consultation with a number of peak bodies in the health sector.
These guidelines are designed to help you understand what documents you can use to substantiate services if you’re asked to participate in a health provider compliance audit.
To access the guidelines go to health.gov.au/hpguidelines
Health Professional Online Services
The Department of human Services offers health professionals access to Online Services through the Health Professional Online Services (HPOS), which is a single entry point, in real-time. You can access information on Medicare eligibility and the processing and payment of claims.
For more information go to humanservices.gov.au/healthprofessionals then HPOS logon
eLearning modules are a flexible and easy learning option for busy health professionals. There are introductory to advanced level modules on the MBS and Pharmaceutical Benefits Scheme (PBS).
For more information go to humanservices.gov.au/healthprofessionals
For more information
The organisations and websites listed below may be able to provide further information. For more detailed information about your administrative record keeping legal obligations, refer to your federal and state law.
Australian Association of Practice Managers aapm.org.au
The Australian Association of Practice Managers:
- represents and unites practice managers and the profession of practice management throughout the
- promotes professional development and the code of ethics through leadership and education, and
- provides specialised services and networks to support quality practice management.
The Australian Medical Association (AMA) is the peak membership organisation representing the registered medical practitioners (doctors) and medical students of Australia.
The AMA promotes and protects the professional interests of doctors and the health care needs of patients and communities.
Professional Services Review
The Professional Services Review Agency (PSR) was established in July 1994 to protect the integrity of the MBS and the PBS. The PSR is part of a strong regulatory regime that ensures appropriate and cost-effective clinical services are delivered through the MBS and the PBS. The PSR provides the legislative framework within which services provided by a practitioner may be peer reviewed in response to a request from the Department.
The Royal Australian College of General Practitioners
The Royal Australian College of General Practitioners (RACGP) is Australia’s largest professional general practice organisation and represents urban and rural general practitioners (GPs).
The College’s mission is to improve the health and wellbeing of all people in Australia by supporting GPs, general practice registrars and medical students through its principal activities of education, training and research and by assessing doctors’ skills and knowledge, supplying ongoing professional development activities, developing resources and guidelines, helping GPs with issues that affect their practice, and developing standards that general practices use to ensure high quality healthcare.
Rural Doctors Association of Australia
The Rural Doctors Association of Australia (RDAA) is a national body representing the interests of rural medical practitioners right around Australia. They are committed to building and maintaining a workforce of highly skilled and motivated rural medical practitioners.
Primary Health Networks
Primary Health Networks (PHN) was established in July 2015 to increase the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes, and to improve coordination of care to ensure patients receive the right care in the right place at the right time. PHNs work directly with general practitioners, other primary health care providers, secondary care providers and hospitals to facilitate improved outcomes for patients.
National Archives of Australia
The National Archives of Australia provides an overview of records management and what you need to have in place.
Australian Government Services Fraud Tip-Off Line
Each year millions of dollars in taxpayers’ money is lost due to fraud against social, health and welfare services and payments.
The Department recognises that most people are honest and use government resources appropriately. However, if information is available about someone who may be misusing these resources, or if fraud is suspected call the Australian Government Services Fraud Tip-Off Line on 131 524 (call charges apply).