Education guide - Health assessments and your record keeping responsibilities

Information about health assessments and your record keeping responsibilities for Medicare items 701 to 707 and 715.

Using health assessments

A health assessment is the evaluation of a patient’s health and wellbeing. General practitioners (GPs) use it to help decide if a patient needs:

  • preventive health care
  • education to improve their health and wellbeing

We recommend you also read the relevant Medicare Benefits Schedule (MBS) item descriptors and explanatory notes available at MBS Online website.

Health assessment items

Item number Short description Used for Time requirements
701 Brief health assessment A simple health assessment 30 minutes or less
703 Standard health assessment A straightforward assessment where the patient does not have complex health issues, but may need more attention than what is provided in a brief assessment More than 30 but less than 45 minutes
705 Long health assessment An extensive assessment, where the patient has a range of health issues that need more in-depth consideration and if necessary, longer term plans More than 45 but less than 60 minutes
707 Prolonged health assessment A complex assessment of a patient with significant, long term health needs that need to be managed through a comprehensive preventative health care plan 60 or more minutes
715 Health assessment Patients of Aboriginal and Torres Strait Islander descent No time requirements but must meet MBS criteria

Patient eligibility

Items 701, 703, 705 and 707 Frequency of service
People 40 to 49 years of age with a high risk of developing type 2 diabetes as determined by the Australian Type 2 Diabetes Risk Assessment Tool Once every 3 years
People 45 to 49 years of age who are at risk of developing chronic disease Once only
People 75 years of age and older Annually
Permanent residents of residential aged care facilities Annually
People with an intellectual disability Annually
Refugees and other humanitarian entrants Once only
Former serving members of the Australian Defence Force Once only
Item 715 Frequency of service
Patients of Aboriginal and Torres Strait Islander descent Once every 9 months

Record keeping obligations

All health professionals must keep up to date records when they claim MBS items for services that receive a Medicare benefit. Records should be completed at the time of service, or as soon as possible afterwards, and include the following details:

  • clearly identify the patient’s name
  • have a separate entry for the health assessment
  • include the date the service was provided or initiated
  • have information about the health assessment, including outcomes and recommendations
  • be clear so, if necessary, another health professional can read the health assessment record and continue the patient’s ongoing care

Offer the patient a copy of the health assessment, including recommendations.

Your professional peak body can give you more advice about record keeping requirements.

More information

Online:

Contact us for Medicare provider enquiries.

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Page last updated: 15 September 2016

This information was printed Friday 9 December 2016 from humanservices.gov.au/health-professionals/enablers/education-guide-health-assessments-and-your-record-keeping It may not include all of the relevant information on this topic. Please consider any relevant site notices at humanservices.gov.au/siteinformation when using this material.