Policy: Injury Reports to Doctors Etc

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Athletic Sports Massage Canberra

Policy: Injury Reports to Doctors

1. Purpose

This policy ensures all injury reports prepared by Athletic Sports Massage Canberra for medical practitioners are accurate, timely, professional, and compliant with Australian privacy and health regulations.

2. Scope

This policy applies to all therapists and administrative staff involved in observing, documenting, and reporting injuries sustained by clients during treatment, sporting activities, or referred assessments.

3. Policy Statements

3.1 Accuracy and Objectivity

• Injury reports must be factual, detailed, and free from personal opinions or assumptions.
• Reports must include:
  • Client’s full name, date of birth, and contact information.
  • Date and location of injury.
  • Description of how the injury occurred (as reported by the client or observed by the therapist).
  • Clinical observations (e.g., range of motion restrictions, bruising, swelling, reported pain levels).
  • Immediate care or first aid is provided.
  • Recommendations for medical referral or further investigation (if applicable).

3.2 Privacy and Confidentiality

• All client information must be handled in compliance with the Privacy Act 1988 (Cth) and any applicable State legislation.
• Injury reports are considered confidential documents and will only be shared with:
  • The referring or treating doctor.
  • Other healthcare providers are involved in the client’s care (with the client's consent).
  • Insurers or legal representatives, if required and with appropriate authorization.
• Client written consent must be obtained before forwarding any report unless legally exempted.

3.3 Professional Standards

• Reports must be written using clear, objective, and professional language.
• Reports must be typed, signed, and dated by the treating therapist.
• The therapist's full name, qualifications, and provider number (if applicable) must be included.

3.4 Timeliness

• Injury reports must be completed and sent to the doctor within 48 hours of the incident, consultation, or request.
• Any delays must be documented and the referring doctor notified where appropriate.

3.5 Secure Handling and Transmission

• Reports must be sent using secure methods, such as encrypted email, secure medical portals, secure faxes, or hand delivery.
• Copies must be stored securely within the client’s clinical file for a minimum of 7 years (or longer if required under Australian law).

3.6 Internal Review

• Injury reports must be reviewed by a senior therapist or clinic manager before being released.
• Any discrepancies, missing information, or concerns must be addressed prior to sending the final report.