Feedback and Complaints Policy
1. Scope of Policy
1.1. The purpose of this Policy is:
a) to ensure the clinical records and client information systems of Jowell Chew Psychology (“the Practice”) are managed in accordance with the compliance obligations of AHPRA-registered Practitioners; and
b) to ensure individuals engaged by the Practice (hereafter Staff and Practitioners) understand their obligations in relation to retaining and digitising records received or generated by the Practice.
1.2. This Policy is intended to be supportive of the Practitioner’s structured professional judgment with respect to the existing obligations of Practitioners under the AHPRA Code of Conduct and the APS Code of Ethics.
1.3. This Policy is intended to complement Jowell Chew Psychology’s Privacy Policy which deals with the collection, use and disclosure of personal information.
1.4. The Practice adopts the single record system of storing client data set out by the Australian Psychological Society in its Position Statement available on the APS website.
1.5. This Policy may be disclosed to Clients so that they may be made aware of the Practice’s policies.
2. Application
2.1. The Practice is committed to effective processes for Record Retention to preserve its history, ensure that critical records are available to meet business needs, comply with legal requirements, optimise the use of space, minimise the cost of record retention, and ensure that outdated and useless records are destroyed.
2.2. This policy applies to all Staff and Practitioners of the Practice and in relation to all Records generated in the course of the Practice’s services and business activity. It is the responsibility of all Staff and Practitioners to adhere to the guidelines specified in this policy. The Practice Manager may require any Staff or Practitioners to generate a record of their observance of this policy.
2.3. By not adhering to the standards set out in this policy:
a) the Practice risks breaching its compliance obligations;
b) Practitioners risk breaching their professional obligations and/or increasing their risk of a claim; and
c) the Practice risks expending resources unnecessarily retaining material.
3. Single Record Categories
3.1. In accordance with the principles for single record management, all client information on the Practice’s Client Management System shall distinguish between:
a) Sensitive Appointment Information, accessible to all support staff; and
b) Sensitive Health Information, accessible only to:
i. the treating Practitioner,
ii. the Practice Manager, and
iii. any other person in the Practice nominated by the Practitioner or the Practice for the purpose of continuity of care.
3.2. Both Sensitive Appointment Information and Sensitive Health Information are subcategories of Sensitive Personal Information, as that term is defined in this policy, the Practice’s Privacy Policy and in the Australian Privacy Principles. Both Sensitive Appointment Information and Sensitive Health Information constitute the Clinical Record for a Client.
3.3. Sensitive Appointment Information includes all information necessary for Staff and/or Practitioners to facilitate ongoing appointments of the Client, including:
a) the date and time a psychology service took place;
b) the purpose of the psychological service;
c) the type of psychological service delivered;
d) how the psychological service was provided (e.g., face-to-face, Skype or telephone);
e) the setting in which the psychology service took place (e.g., community clinic, outpatient service or inpatient ward);
f) a summary risk assessment and plan for intervention, if appropriate;
g) appropriate alerts;
h) the date of any next appointment (if relevant); and
i) any other information of a similar nature.
3.4. Sensitive Health Information means physical or psychological health information and records about an individual collected in the course of delivering Psychological Services, including:
a) detailed descriptions of assessments and interventions applied;
b) detailed description of client mental state examination, vulnerabilities and, appropriately de-identified, protective factors;
c) diagnoses and case formulations;
d) transcripts (if retained);
e) objective data and subjective professional observations;
f) analyses of behaviour change;
g) references to expert opinions and judgements;
h) summaries of the clinical impression/working hypothesis, if appropriate;
i) details of reports and information prepared for internal/external parties;
j) incident reports;
k) consent form(s);
l) psychological tests;
m) any other supporting data; and/or
n) any other information the Practitioner considers to be Sensitive Personal Health Information.
4. Session Notes
(For the avoidance of doubt, Session Notes may include any combination of the above items and are necessarily Sensitive Health Information.)
4.1. Practitioners must take adequate records of the delivery of psychological services (Session Notes).
4.2. Adequate records means records that contain:
a) accurate, current, and complete records of psychological services delivered to the client;
b) sufficient detail to permit planning for continuity in the delivery of psychological services;
c) adequate detail, namely:
i. general factual descriptions of the issues of all presenting parties;
ii. risk assessments;
iii. case conceptualisations;
iv. rationale for interventions and records of informed consent;
v. progress reports;
vi. sufficient detail for another psychologist to understand the client’s circumstance, the nature of the psychological services provided, and the response to interventions; and
vii. sufficient detail for another psychologist to understand and build upon the services the Practitioner has provided, at a level of detail necessary to demonstrate the engagement and reasoning of the Practitioner’s professional judgment;
d) specific detail relating to assessments or interventions involving physical contact with the client (as required per clause 4.8(d) of the AHPRA Code of Conduct);
e) specific detail relating to multiple relationships (as required per clause 4.9 of the AHPRA Code of Conduct);
f) specific detail relating to simultaneous services (as required per clause 4.10 of the AHPRA Code of Conduct);
g) incident reports, including any disclosure of harm or threat of harm, follow-on questions, referral/reporting processes, and outcomes; and
h) referral information, including:
i. all out-referrals to external stakeholders (including confirmation the referral has been received); and
ii. all in-referrals from external stakeholders.
4.3. Practitioners may use clinical judgement whether information that may cause harm to the client (should the information be released without the client’s consent) ought to be retained.
4.4. The content of client records must accord with the professional standards set out under clause 8.5 of the AHPRA Code of Conduct.
4.5. The AHPRA Code of Conduct specifies that informed consent must be recorded at key points of the therapeutic relationship. Records of informed consent are a key component of a Client’s Clinical Record.
5. Practitioner Personal Records
5.1. Practitioners are encouraged to maintain personal records demonstrating:
a) supervision records;
b) continuing professional development activities;
c) self-monitoring exercises or practices;
d) ethical or professional boundaries file note reflections; and
e) insurance notifications.
6. Record Retention General Principles
What Records Are Retained?
6.1. Items specified in the Retention Schedule at Appendix 1 are to be kept for the period specified in the schedule.
6.2. Staff and Practitioners are expected to exercise independent judgement as to the relevance of any record and its connection to an item in the Retention Schedule.
Record Retention
6.3. Not all documents need be retained as records. Documents that fall into the following categories may generally be deleted on receipt:
a) duplicates;
b) early revisions of documents ultimately retained in final form;
c) internal correspondence not relevant to any item in the Retention Schedule;
d) enquiries not leading to engagement of a client;
e) queries from other practices;
f) administrative notes from third parties of no consequence;
g) requests for address or email changes (or similar); and
h) inconsequential internal notes.
6.4. The following principles apply:
a) Emails are not automatically saved to a relevant internal file or client file. Emails relevant to any item in the Retention Schedule are to be retained against that item.
b) For ease of reference and retention (and noting every inbox may be accessed by the Practice), Staff and Practitioners are discouraged from utilising their Practice email for personal correspondence.
c) The Practice will archive email for six months after deletion, after which time deleted emails will be permanently deleted.
7. Digitisation of Clinical Records
7.1. The Practice is a paper-less practice and, subject to the file retention obligations of Practitioners, should not retain original documents.
7.2. When paper health record documents are converted into digital images by scanning, the original paper documents are known as source records. After scanning, source records are destroyed confidentially, as scanned records are considered true records.
7.3. Certain source records are retained in accordance with the Retention Schedule at Appendix 1.
Benefits of Digitisation
7.4. Digitisation of clinical records provides the following benefits:
improved record availability and online accessibility;
simultaneous multi-user access to records;
improved efficiency by eliminating paper-based retrieval delays;
enhanced record security through access and edit controls;
electronic audit trails and activity tracking; and
reduced physical storage space requirements.
Timely Digitisation
7.5. All original documents collected by the Practice must be stored on the Practice Management Software at the earliest possible convenience and, in any event:
a) no later than five business days after a client session in relation to Session Notes; or
b) no later than two business days in relation to any other original documents received or generated by the Practice.
Digitisation Standards
7.6. Minimum requirements for digitisation of original documents:
• Type of document: text based or handwritten
• Colour mode: colour (includes colour, black & white or grey-scale bi-tonal)
• Resolution: 200 dpi
• Compression: JPEG 70%
• Output format: JPEG or PDF
• Hardware: automatic paper feed scanner (not an “app” or manual feed scanner)
7.7. While Staff and Practitioners may utilise scanners outside the Practice office, no Staff or Practitioner should utilise any scanning device without first ensuring the above specifications are met by the outputs.
7.8. A3 original documents and larger must be scanned by the Practice.
Digitisation Workflow
7.9. Where original documents are received or generated in physical form, the following procedure must be followed:
the Practitioner or support Staff member (as directed) digitises the documents in accordance with the digitisation standards;
the Practitioner reviews scanned documents for image quality;
the Practitioner or support Staff member uploads to the Practice Management Software;
requisite meta-data is inputted (coversheet or within the Practice Management Software);
original documents are placed in a holding file pending disposal.
7.10. Digitised documents must contain the following meta-data (either in the document or within the Practice Management Software):
a) document author;
b) description of records/class of records;
c) changes to the record;
d) document publication or creation date; and
e) date scanned document created.
Return or Destruction of Source Documents
7.11. All temporary source documents (including records of deceased clients) will be either returned to the owner or retained for a minimum of 6 months prior to disposal following quality control activities.
7.12. The Practice must undertake quality control audits of the Practice Management Software no less frequently than every six months.
7.13. Once digitised and filed, the Practitioner may act or direct a Staff member to:
a) dispose of the document after six months (e.g., handwritten notes, original test results);
b) return the document to the client (client-provided/owned documents); or
c) return the document to the referring clinic or practitioner (e.g., another practitioner’s handwritten notes).
7.14. Documents that are unable to be returned to the client must be physically stored on the office premises.
8. Record Destruction
8.1. The Practice shall maintain:
a) a Clinical Record document destruction register; and
b) a general document destruction register.
8.2. Documentation of the destruction of Clinical Records shall include:
• Recordkeeping metadata (minimum):
o record identifier (unique unit record number);
o description of records/class of records;
o date created;
o changes to the record; and
o applicable disposal information.
• date range of the clinical records (where applicable);
• responsible person approving destruction; and
• evidence of how and by whom records were destroyed.
8.3. If the Practice or a Practitioner is:
a) served with a subpoena;
b) notified of a government audit (formal or informal);
c) notified of a client complaint to AHPRA or any other regulator;
d) involved in any litigation proceeding; or
e) required by law to notify any State or Commonwealth regulator;
(each, a Record Retention Event)
then (notwithstanding any other clause in this policy) no records are to be destroyed until the Practice Manager provides written direction that the Record Retention Event has ceased or clarifies the scope of affected records.
8.4. Any Staff or Practitioner who becomes aware of a Record Retention Event must immediately notify the Practice Manager.
8.5. In the event of a Record Retention Event, the Practice Manager will notify all Staff and Practitioners:
a) when the Event ceases and usual retention processes resume; and/or
b) any residual affected Client Files or Records to which general retention principles will not apply.
9. Client and Third-Party Record Requests
9.1. Ownership of the information in a file is the shared property of the Practice and the Client. Ownership in the documentation of the information is the property of the Practice.
Consent to Disclose a Client File
9.2. Past and present Clients may request a copy of their personal file.
9.3. A request for a Client file must only be made by a Client or their duly authorised guardian or attorney. All requests for disclosure must be written and signed.
9.4. If a Practitioner has concerns, they may require the Client to attend the office prior to disclosure. A current scan of the Client’s identity document may be required (and any authority documents) for authentication of the Client’s signature.
9.5. Where the request is made by a duly authorised guardian or attorney, the Practitioner must be satisfied the authorisation is valid, within scope, and for a proper purpose.
Disclosing Client Files
9.6. Before releasing a file to a Client:
a) Practitioners may remove procedural notes from the Client file;
b) Practitioners may remove outdated information that may, in their professional judgement, cause harm or adverse effects;
c) the Practitioner may advise the Client to obtain legal advice before disclosure; and
d) the Practice or Practitioner may impose a reasonable fee for collation and release. Unless the file is required for a medical reason, payment may be required prior to release.
Third Party Requests
9.7. Requests for disclosure under court orders or legal obligations must be handled according to law and, secondly, with regard to the professional judgement of the Practitioner.
10. Previously Engaged Practitioner Requests
10.1. The Practice will retain the records of all Clients previously engaged by the Practice in accordance with this Policy.
10.2. A Prior Practitioner may provide a written consent signed by a Client requesting their file be transferred to the Prior Practitioner.
10.3. If a Prior Practitioner requires access to a Client File to respond to a regulator or legal authority, the following applies:
a) the Prior Practitioner must specify the Client files sought in detail;
b) provide independent evidence of the legal need (e.g., letter from a legal representative);
c) pay the reasonable administration fee associated with release; and
d) the Practice will then disclose the requested Client Files.
10.4. A Prior Practitioner may only request parts of a Client File for the period they were the principal treating psychologist.
11. Definitions
11.1. Client means a client of the Practice.
11.2. Client File means all Client information stored on the Practice’s information system in relation to a specific Client (including Sensitive Personal Appointment Information and Sensitive Personal Health Information).
11.3. Personal Information has the meaning in the Privacy Act 1988 (Cth).
11.4. Sensitive Personal Information has the meaning in the Privacy Act 1988 (Cth) and includes:
a) information or an opinion about an individual’s:
i. racial or ethnic origin;
ii. political opinions;
iii. membership of a political association;
iv. religious beliefs or affiliations;
v. philosophical beliefs;
vi. membership of a professional or trade association;
vii. membership of a trade union;
viii. sexual orientation or practices; or
ix. criminal record;
b) physical and psychological health information about an individual; or
c) appointment information (Sensitive Personal Appointment Information);
d) genetic information not otherwise health information;
e) biometric information used for automated biometric verification or biometric identification; or
f) biometric templates.
11.5. Practice Manager means the person with that title, who at the time of adoption is Jowell Chew.
11.6. Practice Management Software means Zanda.
11.7. Prior Practitioner means a Practitioner previously engaged by the Practice who has since ceased engagement.
11.8. Record means any form of recorded information, received or created, regardless of form including paper, electronic, audio, video, data within business systems, and photographs.
11.9. Regulator means the Australian Health Practitioner Regulation Agency.
11.10. Session Notes means any record created as a result of delivering psychological services.
11.11. Staff and Practitioners means any individual engaged by the Practice, including employees and contractors.
12. Implementation
12.1. It is the expectation of the Practice that all Staff and Practitioners comply with this policy.
12.2. All employees, Staff and Practitioners are obliged to report any apparent or potential breach of this policy to the Practice Manager.
12.3. This policy is reviewed periodically to ensure compliance with legislative changes and best practices. Staff and Practitioners will be notified of significant updates.
12.4. This version was adopted on 27 January 2026.
Appendix 1 – Retention Schedule
Client Records
• Sensitive Personal Health Information (including Session Notes, Reports and Assessments)
7 years after cessation of client engagement
If the client was under 18 at the time of collection: retain until at least age 25
If the client identifies as Aboriginal and/or Torres Strait Islander: best practice is to retain indefinitely
• Sensitive Personal Appointment Information
Immediately after cessation of client engagement
• Credit card records (digital records showing customer credit card number)
Immediately after cessation of client engagement
• Medicare records
7 years
Accounting, Finance, and Tax
• Accounts Payable ledgers and schedules: 7 years
• Accounts Receivable ledgers and schedules: 7 years
• Annual Audit Reports and Financial Statements: Permanent
• Annual Audit Records (work papers and related documents): 7 years after completion of audit
• Annual Plans and Budgets: 4 years
• Bank Statements and Cancelled Cheques: 7 years
• Employee Expense Reports: 7 years
• General Ledgers: Permanent
• Interim Financial Statements: 7 years
• Invoices: 7 years
• Notes Receivable ledgers and schedules: 7 years
• Payroll Tax Records: 7 years
• Tax Bills, Receipts, Statements: 7 years
• Tax Returns: 7 years
• Sales/Use Tax Records: 7 years
• ATO or other Government Audit Records: 7 years
Contracts
• Contracts and related correspondence (including proposals that resulted in the contract and supporting documentation): 7 years after cessation or termination of the contract period
• Client Agreements: 7 years after cessation of service
Governance Records
• Governance Records (minute books, signed minutes of Board/committees, corporate seals, articles of incorporation, bylaws, annual corporate reports): Permanent
• Licenses and Permits: Permanent
Insurance Records
• Annual Loss Summaries: 10 years
• Audits and Adjustments: 7 years after final adjustment
• Certificates Issued to A2P: Permanent
• Claims Files (including correspondence, medical records, injury documentation, etc.): Permanent
• Insurance Policies (including expired policies): Permanent
• Journal Entry Support Data: 7 years
• Loss Runs: 10 years
• Releases and Settlements: 25 years
Legal Files and Papers
• Legal Memoranda and Opinions (all subject matter files): 7 years after close of matter
• Litigation Files: 1 year after expiration of appeals or time for filing appeals
• Court Orders: Permanent
Personnel Records
• Employee Deduction Authorisations: 7 years after cessation of employment
• Payroll Deductions: 7 years after cessation of employment
• Tax File Number Declaration Forms: 7 years after cessation of employment
• Superannuation Standard Choice Form: 7 years after cessation of employment
• PAYG Certificates: 7 years after cessation of employment
• Garnishments, Assignments, Attachments: 7 years after cessation of employment
• Labour Distribution Cost Records: 7 years
• Payroll Registers (gross and net): 7 years
• Employee Earnings Records: 7 years after cessation of employment
• Employee Medical Records: 7 years after cessation of employment
• Employee Personnel Records (attendance, applications, job/status changes, performance, termination papers, withholding, garnishments, test results, training/qualifications): 7 years after cessation of employment
• Employment Contracts (individual): 7 years after cessation of employment
• Employment Records (correspondence with employment agencies and job ads): 1 year
Work Health and Safety
• Record of a “notifiable incident”: 5 years
• Workplace Incidents: 7 years
Document details
Approved by: Jowell Chew
Version: 1
Approval date: 27 January 2026
Next Review: 1 August 2026
