NDIS Policies and Procedures Manual – Core Module
Document Number: CM-POL-035
Document Control
This table shows a record of significant changes to the document.
| Legal Name: | Holistic Healthcare Management Services |
| ABN: | 20695058096 |
| ACN: | 695058096 |
| Primary address/head office: | 15 Agasse Way, Tapping WA 6065 |
| Document Name: | NDIS Policies and Procedures Manual – Core Module |
| Document Number: | CM-POL-035 |
| Approved by: | Director |
| Date Approved: | February 2026 |
| Version No: | 1.0 |
| Comments: | Initial Release of the Policies and Procedures Manual |
| Next Review Date: | February 2026 |
Introduction
This policy provides a structured and consistent approach to the creation, approval, revision, distribution, storage, archiving, and retirement of all Holistic Healthcare Management Services documents. It ensures compliance with regulatory obligations, best practices, and quality assurance standards, promoting clear communication and accountability across the organisation.
Scope
This policy applies to all staff, contractors, and volunteers who create, review, approve, or use controlled documents, including policies and procedures, guidelines and protocols, forms and templates, records and registers, and work instructions.
Definition
| Term | Description |
|---|---|
| Controlled Document | Officially approved document managed under version control. |
| Version Control | Systematic tracking and management of document revisions. |
| Master Copy | The authoritative, final version of a document. |
| Document Owner | Person responsible for maintaining the accuracy and compliance of the document. |
| Archive | Storage location for superseded or retired documents. |
| Retention Period | Duration documents must be retained based on legal or regulatory obligations. |
Policy Statement
Document Creation
Documents must be drafted using approved organisational templates, ensuring consistency in format, layout, and branding. The Document Owner must be clearly identified with accountability for accuracy, and drafts must be marked as “Draft” and securely stored.
Approval Process
Every document must undergo formal approval by the designated Document Owner and relevant executives. High-risk, governance, financial, clinical, or regulatory-related documents require formal endorsement from the Board, Executive Committee, or delegated governance group.
Version Control
The organisation adopts a standardised version numbering system (major updates like v1.0 to v2.0, minor updates like v2.0 to v2.1) and maintains a detailed revision history table for each controlled document.
Document Review, Distribution, and Archiving
Document Review
Documents must be reviewed at least every 12 months, or more frequently triggered by legislative changes, audit results, operational incidents, or stakeholder feedback.
Distribution and Accessibility
Master copies are centrally stored in the organisation’s approved Quality Management System (e.g., SharePoint) to ensure a single source of truth, with printed controlled documents clearly marked with specific controlled details.
Archiving and Retention
Superseded documents must be promptly archived in a secure location with retention periods complying strictly with statutory, legislative, and regulatory requirements.
Document Retirement
Documents that are no longer applicable or compliant must be formally retired, marked as “Retired”, moved to secure archives, and communicated promptly to all staff.
Compliance Monitoring and Auditing
Annual internal audits of document management practices are scheduled and conducted by the Quality and Compliance team to review version control, review timeliness, archiving, and staff usage, with non-conformance findings recorded through Corrective Action Reports (CARs).
Roles and Responsibilities
| Ref No | Roles | Responsibilities |
|---|---|---|
| 1 | Document Control Coordinator | Oversees document management system, maintains Document Register, and archives documents. |
| 2 | Document Owner | Ensures accuracy, compliance, approves documents, and manages reviews. |
| 3 | Subject-Matter Experts (SMEs) | Review documents, ensuring they align with current best practice and standards. |
| 4 | Quality & Compliance Team | Conducts audits, identifies gaps, and ensures continuous improvement. |
| 5 | Workers | Use current documents only, and promptly report any discrepancies or issues. |
Related Documents
- Document Management Procedure
- Records Management Policy
- Internal Audit Procedure
- Continuous Improvement Policy
- Governance and Delegations Policy
- Corrective Action Procedure
- Staff Training and Development Policy
References
- ISO 9001:2015 (Clause 7.5 – Documented Information)
- NDIS Practice Standards (Module 2: Governance and Operational Management)
- Health Records and Information Privacy Act 2002 (NSW)
- Privacy Act 1988 (Cth)
- Australian Standard AS ISO 15489-1: Records Management
Policy Review
This policy will be reviewed annually to incorporate changes in financial regulations, NDIS guidelines, and organisational needs, with adjustments made based on financial audits, stakeholder feedback, and risk assessments.
