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22.2.1 Creating a transparent Audit Trail
- Record the request on Defcare under Employee notes with an appropriate heading e.g. SURGERY, PHARMACY, TREATMENT AUTHORITY ISSUED. Remember to identify yourself as the author of any information under these headings as this information is altered if someone else enters additional information.
- Include details of who made the request, the exact nature of the request, the date for treatment, the cost and the location. This should make sense to anyone looking at Defcare, especially administrative staff trying to pay accounts. Accounts cannot be paid without a record of specific prior-approval, or standing Treatment Authority on Defcare. Failure to record approvals means that administrative staff will need to investigate accounts before they can be paid. This is a very time consuming process and unnecessary if approvals or rejections are correctly documented on Defcare and the file. The Payment Specific Note function exists for this purpose.
- When engaging a client after September 2012, issue them with a Treatment Authority letter and save to the client's E-File on TRIM and send a copy to the home state to file in the client's SRCA paper file.
- For prior-approval category treatments, create a written approval letter, using Defcare Standard Letters or fax and forward to the appropriate parties i.e. the requesting practitioner, the health care facility, the client and the file.
- Where prior-approval treatment has been declined, ensure the reason for this is clearly reflected in written notification to all relevant parties. If a medical or health advisor has been asked to comment on the case, and recommended that treatment should be declined, ensure that they write a Minute to reflect their recommendation and that this is attached to the file. Remember this is a reviewable decision so reasons for denial must be clearly stated in a saved Standard Letter on Defcare.
- All documentation should reflect your decision making process and be clear to any one reading the file or Defcare.
The following guidelines detail the main types of quasi- medical treatment. There will be some requests from clients for services that are not specifically mentioned. Without being inclusive such requests could include acupuncture, relaxation programs etc. The same basic principles will apply in those situations as appears in the handbook. However any request should always be considered in the light of addressing the 'reasonableness' of the requested medical treatment as defined in the SRCA and as detailed in this handbook.