Title Page

  • Site conducted


  • Division

  • Region

  • Clinic

  • Clinic

  • Clinic

  • Region

  • Clinic

  • Clinic

  • Clinic

  • Region

  • Clinic

  • Clinic

  • Clinic

  • Clinic

  • Clinic

  • Region

  • Clinic

  • Clinic

  • Clinic

  • Region

  • Clinic

  • Clinic

  • Clinic

  • Clinic

  • Prepared by

  • Conducted on

  • Client Name

  • Client ID (C-Number)

Checklist Instructions

  • Checklist is to be completed by Clinicians when reviewing their own client files.

    Clinicians should review 6 client files (3 new and 3 return HSP clients who have completed a claimable assessment (600/800) and received a full fitting program) since 1/9/22.

    Documentation should be reviewed from the DM files tab. If missing documentation is identified, check the compliance folder &/or DIGIform portal to determine if draft form is available.
    The review should be undertaken authentically. This is a self-learning activity - use the opportunity to ensure you are compliant with legislative, clinical and business requirements.

    The checklist verifies against specific HSP & best practice requirements .

    Check the evidence and documentation on the file against each requirements. Choose if the requirement is applicable to the client. Read each question:
    • Choose 'YES ' response if client records clearly document the requirement
    • Choose 'NO' response if client records do not or do not fully document the requirement
    • Choose 'N/A' if not relevant to client

    Further information may be found in the HSP Schedule of Service Items, by referencing the applicable Audika policy /Work Instruction (if applicable), or from a Clinical Trainer.

    The last section 'Clinician Comments' provides space for the Clinician to provide comment on individual client files (if applicable)

Clinician Self File Review

File Review

Legislative Requirements

  •  All relevant legislative requirements must be met for compliance

  • Client consent signed AND dated (on Preassessment form)? <br> <br> Refer to P02C002, Adult Clinical Consent Policy; W02A025, HSP Client Consent Requirements

  • Relocation consent signed AND dated (if applicable) <br> <br> Refer to W02D007, Managing HSP Client Relocations & W02D047, Managing HSP Relocations In for further information

  • Does the client qualify for Specialist Services?<br><br>Refer to W02A014, Specialist Services Notification Requirements for further information

  • Has the portal been updated?

  • Has the discussion and client preference been documented?

  • Do Minimum Hearing Loss Threshold (MHLT) requirements apply? (3FAHL <23 dB in either ear)<br><br>Refer to W02C048 , Minimum Hearing Loss Threshold for further information

  • Has the Minimum Hearing Loss Threshold (MHLT) form been completed, documenting the exemption criteria?

  • Has the WANT form been completed with a total score of ≥ 5, signed AND dated prior to fitting?

  • Have fully subsidised device options been offered?<br>Ensure device model and style are also documented<br><br>Refer to P02A002, Best Practice Clinical Standards –Hearing Rehabilitation (Hearing Devices) for further information<br>

  • Telecoil information provided, and where fitted device(s) do not have telecoil, client’s decision to opt out is documented?<br><br>Refer to P02A002, Best Practice Clinical Standards –Hearing Rehabilitation (Hearing Devices)

  • Quote & Purchase Terms Agreement (QAPT) signed AND dated prior to fitting, for all devices fitted?<br><br>- Devices on QAPT must exactly match devices provided <br>- QAPT must include the correct maintenance co-payment amount.<br><br>P02D010, Quote and Purchase Terms Policy for further information

  • Eligibility Criteria for Refit met and clearly documented? (if applicable)<br><br>Refer to W02C008, Refit and Replace (HSP Clients) for further information<br>

  • Eligibility Criteria for Refit worksheet uploaded?

Other Critical HSP Requirements

  • Fitted devices have minimum 10dB reserve gain at 500-4k Hz (or evidence of HSP exemption on file)?<br><br>Refer to P02A002, Best Practice Clinical Standards –Hearing Rehabilitation (Hearing Devices); W02C063, HSP -Determine Sufficient Gain for further information

  • Private Services & Device Acknowledgement form completed? <br>(Applicable where Client has paid for any private services, accessories, recharge dock or private devices)<br><br>Note: If accessories or recharge docks are funded by a 3rd party, e.g. Home Care Package or DVA, a private services form is not required. <br><br>Refer to W02C020, Devices Privately Purchased by HSP Clients for further information<br>

  • Were SMART COSI goals established, reviewed AND dated? <br> Refer to P02A002, Best Practice Clinical Standards –Hearing Rehabilitation (Hearing Devices)

  • Has aided speech testing been completed?<br><br>Refer to P02A002, Best Practice Clinical Standards –Hearing Rehabilitation (Hearing Devices)

  • Has device usage been reviewed?<br>(Documented either by data logging or reported usage)<br><br>Refer to P02A002, Best Practice Clinical Standards –Hearing Rehabilitation (Hearing Devices)

  • Has the Maintenance Agreement been signed AND dated between fitting and follow up?<br><br>Refer to W02C044, Maintenance Claim Form and Maintenance Agreement Requirements

  • If the client does not have Maintenance, has their decision to opt out been documented?

  • Are all claim forms uploaded correctly?<br> All claims forms must be signed and have the correct dates. Fitting forms must also have the correct device code and cost to client.

Other Forms and Supporting Documentation

  • Has the Preassessment form been uploaded? <br>

  • Has an Assessment form been uploaded?

  • Has a Rehabilitation Program & Device Selection form been uploaded? Either standalone or as part of an Assessment/Review form

  • Have COSI been uploaded?

  • Has the Fitting form been uploaded?

  • Has the Follow Up form been uploaded?

  • Has the Audiogram .xml file been uploaded to the Audiograms tab in DM?

  • Has the Audiogram .pdf been uploaded to the Files tab in DM?

  • Has the GP report been uploaded?

  • Have the device settings been uploaded?

  • Has the aided speech assessment been uploaded?

Clinical Best Practice Requirements

  • Complete clinical & audiological history (on preassessment &/or assessment form)? <br> <br>Refer to W02C054, Audiological Case History for further information

  • Otoscopy completed at assessment and observations documented?

  • Otoscopy completed at fitting and observations documented?

  • Accurate & complete assessment performed? <br> <br>(Including pure tone audiometry, tympanometry [unless contraindicated] & unaided speech) <br> Refer to P02A001, Best Practice Clinical Standards –Audiological Assessment for further information

  • Where referral requirements are met, report sent to medical practitioner and written medical clearance received prior to fitting if necessary. <br> Refer to P02A005, Best Practice Clinical Standards Clinical Referral & F02C008, Referral Requirements Summary Sheet for further information

  • Justification of device recommendation and reasons for client choice documented <br> <br>Refer to P02A002, Best Practice Clinical Standards –Hearing Rehabilitation (Hearing Devices)

Digital Processes to Support Ongoing Client Care

  • Appointment 'Outcome Notes' completed with summary of service provided and further actions?

Clinician Declaration

  • I, the Clinician, understand that while this self-review is an educational activity, I will resolve any potential non-compliances detected in the process.

  • Additional Comments

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.