What are the four procedures, five processes, and twelve documents?

Producing objective evidence is an essential factor in passing your NDIS audit. One of the difficulties of becoming an NDIS provider is understanding the required documentation as an NDIS provider. How do you know what has to be documented or maintained as an NDIS provider?

There are various ways in answering the question above. This article is focused on the core module of NDIS Practice Standards and Quality Indicators which applies to almost all providers going through the certification audit. This article focuses on the bare minimum required according to NDIS Practice Standards and Quality Indicators. Please note that providers can decide to maintain more evidence due to the size or complexity of their processes, discretion, client demands or any applicable legislative requirements.

The audit criteria are defined as requirements used as a reference against which objective evidence is compared. Your NDIS auditor's scope of work is to evaluate your organisation's activity against specific criteria. The NDIS Practice Standards are the criteria used by your auditors during the certification audit. Therefore, understanding NDIS Practice Standards and Quality Indicators are essential in becoming ready for your audit and in helping you avoid receiving any false or incorrect audit nonconformities.

Incorrect or false audit nonconformities are a nonconformity based on your auditor's opinion and not on the basis of objective evidence or audit criteria.

Below are the key points in reading the core module of  NDIS Practice Standards and Quality Indicators.

Here are the definitions of the key points before reading the standard.

Procedure: defined as an established or official way of doing something. It is preferred to be documented; however, there is no guidance given in the indicator outlining whether the procedures must be documented or not.

Document: defined as a piece of written, printed, or electronic matter that provides information or evidence or that serves as an official record. You should have documented evidence in any media to fulfill the audit criteria.

Process: defined as a series of actions or steps taken to achieve a particular result; however, there is no guidance given in the indicator outlining whether a  process must be documented or not.



There are four Procedures, five processes, and twelve documents that are required to be produced according to the  NDIS Practice Standards and Quality Indicators. Below are the extracts from the standard:


Four that required a procedure:

  1. Violence, abuse, neglect, exploitation, and discrimination
  2. Feedback and complaint management
  3. Incident management
  4. Management of Waste


Five that require a Process:

1.Privacy and Dignity

  • Consistent processes and practices are in place that respect and protect the personal privacy and dignity of each participant.

2.Information Management

  • Documents are stored with appropriate use, access, transfer, storage, security, retrieval, retention, destruction and disposal processes relevant and proportionate to the scope and complexity of supports delivered.

3.Human Resource Management

  • An orientation and induction process is in place that is completed by workers including completion of the mandatory NDIS worker orientation program.

4.Transitions to or from the a provider

  • (3)Processes for transitioning to or from the provider (including temporary transitions referred to in subsection (2)) are developed, applied, reviewed and communicated.

5.Participant Money and Property

  • Where the provider has access to a participant's money or other property, processes to ensure that it is managed, protected and accounted for are developed, applied, reviewed and communicated.


Twelve that required documents:

Governance and Operational Management

1.There is a documented system of delegated responsibility and authority to another suitable person in the absence of a usual position holder in place

2.Perceived and actual conflicts of interest are proactively managed and documented, including through development and maintenance of organisational policies.

Risk Management

3.A documented risk management system that effectively manages identified risks is in place, and is relevant and proportionate to the size and scale of the provider and the scope and complexity of supports provided.

Quality Management

4.The provider's quality management system has a documented program of internal audits relevant (proportionate) to the size and scale of the provider and the scope and complexity of supports delivered.

Human Resource Management

5.The skills and knowledge required of each position within a provider are identified and documented together with the responsibilities, scope and limitations of each position.

6.The performance of workers is managed, developed and documented, including through providing feedback and development opportunities.

Continuity of Supports

7.These needs and preferences are documented and provided to workers prior to commencing work with each participant to ensure the participant's experience is consistent with their expressed preferences.

Access to supports

8.The supports available, and any access / entry criteria (including any associated costs) are clearly defined and documented.

Support Planning

9.in collaboration with each participant: (a) risk assessments are regularly undertaken, and documented in their support plans.

Service agreement with participants

10.Where the provider delivers supported independent living supports to participants in specialist disability accommodation dwellings, documented arrangements are in place with each participant and each specialist disability accommodation provider.

Transitions to or from a provider

11.A planned transition to or from the provider is facilitated in collaboration with each participant when possible, and this is documented, communicated and effectively managed.

12.Risks associated with each transition to or from the provider are identified, documented and responded to, including risks associated with temporary transitions from the provider to respond to a risk to the participant, such as a health care risk requiring hospitalisation.


Correct reading and comprehension of the standards and audit criteria will help you to have a better understanding of your NDIS audit process and be more prepared for the NDIS audit. This article is intended to give an overview of the core module of the NDIS Practice Standards and Quality Indicators. You should produce the above evidence to pass your audit against the core module regardless of your organization's size or complexity. There are some other requirements that may mandate a provider to maintain more than the above points. Additionally, requirements such as local legislative requirements, provider preference, discretion, or client's requirements must be treated similarly.



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