The essential role of defensible documentation in the NDIS

Invoicing and record keeping. They may not be the most exciting parts of life as a National Disability Insurance Scheme (NDIS) provider, but they’re vital.

Whether you’re a fan of hard copy documentation or you opt to keep evidence of your service delivery and claims in electronic form, one thing is clear – maintaining full and accurate records is a must.

We spoke to Angela Harvey, Managing Director of boutique NDIS consulting agency, Supporting Potential, to find out why.

Here’s what she had to say.

By Angela Harvey – Managing Director, Supporting Potential

In the dynamic field of disability services, the importance placed on defensible documentation is greater now than ever before.

While some may view it as a bureaucratic pain, documentation is a fundamental aspect of practice for providers of NDIS supports – one that safeguards participants and protects providers from consequences that can potentially become legal.

What's defensible documentation?

Defensible documentation comprises records that are clear, accurate, and comprehensive.

Currently, in the NDIS, the rules around record keeping vary depending on whether a provider is registered with the NDIS Quality and Safeguards Commission or not.

However, the introduction of uniform standards is expected, and that means every provider should take the opportunity now to focus on getting their house in order.

What do I need to document?

The National Disability Insurance Agency (NDIA) requires providers to maintain complete, truthful, and accurate records to support their claims, including:

• invoices
• service agreements outlining the schedule of supports, the cost, quantity, type, and quality of supports to be delivered, the location of service delivery, and the expected outcomes for the participant
• approved quotes (where appropriate)
• evidence of support type and quantity
• staff rosters
• final reports or assessments

Service agreements are contentious, because the NDIS Practice Standards only require participants to have a clear understanding of the supports they’ve chosen and how they’ll be provided.

So, while it isn’t stated that service agreements need to be documented in writing (except for those related to Specialist Disability Accommodation), the NDIA ‘recommends having a written service agreement so participants and providers are clear about what each party has agreed to.'

Separately, the Commission mandates that registered providers maintain records across a raft of areas, such as:

• the culture, diversity, values, and beliefs of their clients
• consents related to collecting and using personal information, including audio/visual material
• records demonstrating the management and documentation of conflicts of interest
• systems employed for the management of identified risks
• internal audit programs
• records of feedback and complaints received – and related improvement initiatives
• incident records and follow up actions, including participant and worker feedback
• worker pre-employment checks, qualifications, and experience
• training and education records to ensure worker competency
• documentation of worker performance and feedback
• participant needs and preferences that have been communicated to workers
• assessment details and support plans, including participant goals and preferences
• risk minimisation strategies employed in the support of participants
• progress assessments related to a participant’s goals and outcomes
• documentation of participant transitions to or from a service, and evidence the process is managed collaboratively with clients
• medical emergency response protocols
• medication records, including dosage and administration details

The time to get your documentation right is now

Recent legal cases highlight the importance of robust documentation, with courts and regulatory bodies examining NDIS provider records closely to ensure compliance with standards and the protection of participant rights.

Inadequate documentation can lead to severe consequences for providers, including fines and service suspensions. In several cases around the country, providers have faced significant penalties – not only for the absence of support documentation, but also for failing to document essential details that a reasonable person would expect to be recorded.

There’s been an uptick in the number of requests for support our team has received from providers who thought they had appropriate systems and documentation in place, but later found themselves needing to take remedial action following compliance investigations undertaken by the Commission. Examples include providers that:

• failed to report 1.2 per cent of incidents in their system within the Commission’s 24-hour reporting period
• received four requests for evidence regarding the same incident from four different departments within the Commission
• received requests for evidence to demonstrate how they had met their regulated restrictive practice reporting requirements

The benefits of defensible documentation for providers

While requirements around record-keeping can sometimes feel overwhelming, it’s important to remember that defensible documentation not only serves legal and compliance requirements, but also offers significant operational benefits to providers. Value delivered includes:

• quality assurance – helping to maintain high service standards and continual service improvement
• transparency and trust – building trust with participants through fair and responsible service delivery
• effective communication – ensuring all team members are aligned on a participant’s support plan
• financial accountability – crucial for substantiating NDIS claims and reducing disputes over payments

To ensure documentation is defensible, providers should provide regular staff training on the importance of documentation and the techniques to be applied to it, use technology to streamline data collection and management, and conduct regular audits to identify improvements and ensure compliance with the NDIS Practice Standards.

Reliable documentation supports an organisation's sustainability and effectiveness and ultimately aids in protecting the wellbeing of participants.
In an industry focused on supporting vulnerable people, the value of dependable and defensible documentation can’t be overstated.

For more information about invoicing and record keeping, click here.