DVA community nursing documentation requirements
The Department of Veterans’ Affairs sets its documentation requirements in the Notes for Community Nursing Providers. The current edition, effective July 2026, requires an RN’s comprehensive assessment, a signed nursing care plan, contemporaneous progress notes for every visit, scheduled reviews of care, and records that DVA can access on request.
Key takeaways
- Progress notes must be contemporaneous, cover all clinical and personal care given in each visit, and accurately reflect what happened.
- A nursing care plan is developed and signed by an RN and the client (or their authorised representative), and signed and dated after each review, at least every 3 months.
- Reviews run on fixed cycles: 28-day claim period reviews, a three-monthly RN review with a file note, and weekly RN review for Exceptional Case clients.
- Providers must keep referrals, assessments, care plans, progress notes, dated reviews and claiming history, and give DVA access to them on request.
What documentation does the DVA Community Nursing Program require?
The Notes for Community Nursing Providers (effective July 2026) say a provider must develop, maintain and store documentation covering the claiming, administrative and clinical aspects of each client’s episode of care. The Notes list what must be clearly identified and documented: valid referrals, assessments, nursing care plans, clinical progress notes, dated reviews of care and their outcomes, related care documentation, and claiming history. Care documentation must stay up to date and be based on contemporary community nursing industry best practice standards.
What must a comprehensive assessment include?
An RN must assess the client’s nursing care needs through a comprehensive nursing assessment, face to face in the client’s home. It is required on receiving a referral from an authorised source, after transfer from another Community Nursing provider, and at the 12-month anniversary of the start of care (after 13 consecutive 28-day claim periods). The assessment uses validated tools chosen for the client’s needs, for example skin, continence, falls risk (FRAT), sleep, nutritional (using a validated tool) and level of independence. The RN reports the outcomes to the client’s GP, and the outcome is communicated to the client and, where appropriate, their carer.
What must a nursing care plan contain?
The care plan is developed with and tailored to the client, and signed and dated by the RN and the client or their authorised representative. It must include:
- specific clinical and personal care interventions for the assessed needs, and the client’s level of independence;
- agreed days, approximate times, and the frequency and length of visits;
- short and long term goals and objectives for each nursing need;
- all medication interventions, including whether given by an RN or EN or assisted by a personal care worker;
- delegation of tasks within each staff member’s scope of practice;
- aids, appliances or nursing equipment required;
- planned review dates;
- a summary of other health services and supports the client receives; and
- the risks associated with care and how personnel can support the client to manage them.
The plan must be updated when needs, goals, ability, carer support or risks change, or after an incident, and it must be signed and dated after each review, at least every 3 months.
What must clinical progress notes contain?
Care documentation must include contemporaneous progress notes of all clinical and personal care provided during each visit. The Notes require progress notes to be current and accurately reflect the events documented; clear and concise, as specific as possible; able to inform a handover from one visit to the next; readily available to everyone involved in the client’s care; legible, avoiding acronyms and abbreviations; dated and identifying the staff member’s name and qualification; and signed by the staff member where handwritten.
Fictional example. No real client data.
Wound dressed. Client fine. Nothing to report.
14 March 2026, 9.10 am. Visit by J. Nguyen, Enrolled Nurse. Changed the dressing on the left lower leg per the nursing care plan. Wound bed clean, no odour, minimal serous drainage, edges intact; size unchanged from the last visit. Client reported no pain at rest and mild discomfort during the dressing change. Skin around the wound checked, no redness. Next visit: same dressing, report any increase in drainage to the RN. Handover: client asked for a later visit time on Thursday.
How often must care be reviewed?
| Review | What the Notes require |
|---|---|
| Seven-day | Personal Care clients who need help with self-administered Schedule 8 medication from a dose administration aid are reviewed by an RN (or an EN without notation). Exceptional Case clients are reviewed by an RN at least weekly. |
| 28-day | At the end of each 28-day claim period, care and clinical documentation are reviewed to verify the care delivered reflects the items claimed. An RN reviews where clinical care is involved; an RN or EN for Personal Care only. |
| Three-monthly | An RN reviews before the end of every third 28-day claim period, records a file note in the care documentation, documents changes in the care plan, and notifies the GP where services need to change. |
Who can access the records, and for how long must they be kept?
Providers must make care, administrative and claiming documentation available to DVA, or an approved person or organisation, on request, by desktop or on-site review. They must retain care and payment records in line with the medical record retention laws of their state or territory, protect personal information under the Privacy Act 1988 and the Australian Privacy Principles, and restrict access to personnel who need it for their duties.
Where does NoteGate fit?
NoteGate checks community nursing and veterans’ home care notes against program requirements before they are saved, so notes that are vague, undated or missing handover detail are returned to the worker for correction, and it keeps the validation history as part of the record. It supports documentation governance and does not determine compliance with the Notes. See NoteGate for DVA community nursing.
Frequently asked questions
Do DVA progress notes have to be written for every visit?
Yes. The Notes require contemporaneous progress notes of all clinical and personal care provided during each visit, detailing the care that was delivered.
Who signs the nursing care plan?
The RN and the client (or their authorised representative) sign and date it after the comprehensive assessment, and it is signed and dated again after each review, at least every 3 months.
Are these requirements final?
DVA updates the Notes. This guide reflects the edition effective July 2026. Check the DVA page for community nursing providers for the current version before relying on it.
Sources
- Notes for Community Nursing Providers, effective July 2026 (Department of Veterans’ Affairs, retrieved 20 September 2026)
- Information for DVA contracted Community Nursing providers (Department of Veterans’ Affairs, retrieved 20 September 2026)
Related
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See how NoteGate returns vague or incomplete notes for correction.
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