Australian Health Practitioner Regulation Agency - Restriction: Complete audit
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Restriction: Complete audit

National Restrictions Library 2.0: This restriction applies to restictions imposed or accepted from 16 September 2024. For restrictions imposed or accepted before this date please see the National Restrictions Library 1.0.

Restriction description

An auditor must audit the practice of a practitioner with this restriction. The restriction outlines the audit’s focus. Our concerns determine how often and what type of audit happens. 

We must approve the nominated auditor and audit plan to ensure that the audit will focus on the required areas.

The practitioner must show evidence of the completed audit.

We monitor compliance with this restriction by checking:

  • the practitioner meets all required timeframes 
  • the practitioner’s proposed auditor and audit plan will adequately assess the identified concerns
  • the findings of the audit.

Full text of restriction

  1. The practitioner must undergo an audit of their practice (the audit), including any supporting records, by an approved auditor. The audit is to focus on #Board’s concerns# and must include, at a minimum, #audit requirement#.
  2. The practitioner must comply with the Ahpra Protocol: Complete audit (293 KB, PDF) in force at the date these conditions are imposed and then as updated from time to time.  

Option 1: once off

  1. The practitioner must complete the audit within #timeframe# of the start date of this condition. The start date is #date#.

Option 2: ongoing 

  1. The practitioner must complete a period of audits, with the first audit being within #timeframe# of the start date of this condition and thereafter on a #frequency# basis or as otherwise directed. The start date is #date#.   
  2. <include if required> The practitioner must complete a minimum of #number# of audits over a #duration# period.

You will receive a monitoring plan that details contact information, due dates, and the information you will need to provide to show that you are complying with your restrictions.

  • Acknowledging the requirements
    Read and acknowledge:
  • Nominating an auditor
    • Nominate an auditor and include their CV and an audit plan
  • Assessing your nomination
    • Your nomination will be assessed based on the requirements and the Protocol
    • You will be advised if your nomination has been approved or rejected
  • Completing the requirement
    • Undertake audit(s) as per your approved audit plan
    • Provide reports from the auditor as required 
  • Submitting evidence of compliance
    • Submit a final audit report by your approved auditor within the timeframe provided in your monitoring plan
  • Removal of the restrictions
    • We will assess the evidence and consider removal of the restrictions once all associated requirements have been met.
    • You will be advised of the outcome.
  • Removing the restrictions
    • Once approved, the restrictions will be removed from your registration. 

Forms

Please contact your case officer for more information. 

For general information see our Frequently asked questions about Monitoring and compliance page

If you have not yet received contact details for your case officer, please email your enquiry.

We are here to support and guide you through your compliance. 

The contact details for your case officer are included on all our correspondence with you.

We also encourage you to use independent support services, including those provided on our Practitioner support services page.

You can also contact your legal representative or professional union to support you.

Generally, we will provide a further opportunity to nominate a different auditor, or to address any shortfalls in the nomination. 

Repeated failures to make an appropriate nomination and/or delays in providing the required nominations may be considered non-compliance and may result in further regulatory action being taken.

 

Contact your Ahpra case officer as soon as possible. You will be required to provide evidence of discontinuation and make a new nomination within 30 calendar days of the auditor’s withdrawal to complete any outstanding audits. Your new nomination should include either a new audit plan or endorsement from your new nominated auditor that the audit plan remains appropriate (with or without amendment).

It is recommended that you do not commence the audit(s) before we have considered your nomination and approved it. If we do not approve your nomination, any audits undertaken prior to an approval may not be counted towards the requirements of your restrictions and you may be required to complete additional audits at your own cost. 

It generally takes between 4 and 6 weeks for approval of a nomination. 

Audits via videoconference may be considered. Both you and your auditor should confirm in your plan that you have access to reliable internet, web camera, speakers, and microphone and how you will securely share patient records and personal information. Audits via audio communication only is unlikely to be approved. 

The audit plan should also specifically address how the audits will be conducted in the event of issues involving bandwidth, video quality, broadband interruptions, and other technical issues. 

Only audits which include real time interaction with your auditor will be approved. Pre-recorded video and audio content will generally not be considered sufficient in isolation. 

If you maintain paper-based records, it is unlikely that a virtual or remote audit will be approved. 

If your restrictions require you to complete audits at specified intervals and you are unable to complete an audit at the scheduled time due to the availability of your nominated auditor, you may be eligible to apply for an extension of time to complete the audit. Extensions are considered on a case-by-case basis.

If you are ineligible or fail to apply for an extension, then a failure to complete the required audit at the required frequency may be considered non-compliance with the restrictions. We may consider whether this requires further regulatory action. This is considered on a case-by-case basis and includes consideration of the original concerns resulting in your restrictions, any other safeguards in place such as supervision and whether the frequency of the audits was important for the assessment of implementation of remedial actions and or evidence of sustained adjustments to your practice. We may, amongst other actions decide that you must undertake additional audits. 

You may consider applying for an extension of time in order to ensure that there is sufficient sample of patients or procedures for the audit. Extensions are considered on a case-by-case basis and we will consider whether you have provided evidence of the number of patients or procedures in the audit period and/or whether the requirement to obtain evidence of your practice in this area outweighs the number of records or patients audited.

You may also consider requesting a change to your restrictions to take into account a smaller sample of records or patients required for each audit.

If a report indicates there are or continue to be concerns that relate to your conduct or performance, we may consider whether this requires any further regulatory action. This is considered on a case-by-case basis and includes the nature of the original concerns resulting in your restrictions, any remedial action taken by you including completion of education, seeking input from peers and or safeguards that provide adequate protection to the public such as supervision.

You must contact your Ahpra case officer or team as soon as possible if you have had a change of circumstances or are unable to comply with the requirements for any reason. See your monitoring plan for contact information.

 
 
 
Page reviewed 13/09/2024