Records and Documentation Concerns: Why Your Notes Matter When Care Is Questioned

A documentation concern arises when records are missing, inadequate, inaccurate, disrespectful, insecure or altered. Sometimes documentation is the main concern raised. More often, it surfaces during the assessment of another concern, such as clinical care, consent or prescribing, when the records are requested and do not show what the practitioner says happened.

Documentation problems appear in a large share of complaints and notifications. Board annual summaries show documentation as a leading complaint category for several professions; for occupational therapists, for example, documentation accounted for almost one in five complaint types in 2024/25. When a concern about clinical care is assessed, poor records can turn a defensible clinical decision into one that cannot be shown to be reasonable.

Records serve continuity of care, communication within a team, quality improvement, billing, legal evidence and patients' rights to their own information. A record that does all of those things well is also the best protection a practitioner has.

The shared Code of conduct expects accurate, up-to-date, factual, objective and legible records that report relevant clinical history, findings, investigations, information given to patients, medicines and other management, in a form other practitioners can understand. Records must be held securely, show respect for patients without demeaning or derogatory remarks, and be accessible to patients in line with the law. Good medical practice and the Nursing and Midwifery Board's codes contain similar expectations, and some Boards publish profession-specific guidance, for example on dental charting or psychological test materials.

In 2023 Ahpra and the National Boards published a summary of obligations for managing health records and a self-reflective tool. The summary emphasises that:

• each entry should show the date and time, who provided the service and, where relevant, where;
• records should include relevant history, diagnostic and treatment information, advice and correspondence with other practitioners;
• informed consent should be documented, with written consent for higher-risk procedures;
• records should include a management plan and the information needed for continuity of care, including relevant psychological, social and cultural information;
• records should be made at the time of events or as soon as possible afterwards;
• language should be objective, respectful and non-judgemental, without culturally unsafe remarks; and
• practitioners should only access records when involved in the person's care or otherwise authorised.

Altering records to make them look more complete, or to support a particular account, is one of the most serious things a practitioner can do. It is dishonest, it can mislead future clinicians as well as investigators, and it may be a criminal offence in some circumstances. Electronic systems keep audit trails that show who changed what and when, and investigators routinely request them when they suspect alteration.

If you realise after a complaint that your notes are incomplete, do not change them. Explain the gap honestly in your response, describe what you recall and what your usual practice is, and be clear about which is which. Corrections at any time should leave the original visible: a dated addendum, labelled with the actual time it was written and the time of the event it describes.

Adequate and contemporaneous records

For services billed to Medicare or involving PBS prescribing, the Professional Services Review scheme requires an adequate and contemporaneous record. The record must clearly identify the patient, contain a separate entry for each attendance with the date of service and enough clinical information to explain the service, so another practitioner could continue care, and be completed at the time or as soon as practicable afterwards. A service not supported by such a record may be found to be inappropriate practice, which can lead to repayment of benefits. Records also need to support item-specific requirements, such as time thresholds. Billing compliance is covered in our Medicare billing and PSR course.

Retention

Health records laws in New South Wales, Victoria and the ACT require private providers to keep adult records for at least seven years after the last service (in the ACT, after the last entry), and records collected in childhood until the person turns 25. Elsewhere there may be no statutory period for private practitioners, but codes, Board guidance and insurers give similar advice. Plan for your records when you leave, sell or close a practice.

Telehealth, messages and AI scribes

Phone, video and message contacts are clinical encounters that need documentation. If you use an AI scribe, Ahpra's guidance on artificial intelligence makes clear you remain responsible for the accuracy of the record: tell patients and obtain consent, check every draft before it is finalised because AI can omit, invent or misattribute information, and understand how the data is stored. An AI-generated note you sign is your record. Privacy obligations are covered on our page on privacy and confidentiality concerns.

Ahpra assesses documentation as part of its risk assessment of the whole concern. Thin records in an otherwise reasonable episode of care commonly lead to no further action, or to advice or a caution about documentation. A pattern of inadequate records, or records that make it impossible to assess the safety of care, is more likely to lead to an undertaking or conditions such as a records audit, supervision or education. Conditions are usually published on the public register and can be reviewed once you show the risk has been addressed. Altered or fabricated records are treated as a probity matter and can lead to the most serious outcomes.

The physiotherapist's one-liner

A physiotherapist receives a notification alleging he did not explain the risks of spinal manipulation. His note for the session records only the technique, that the patient tolerated it well and the review date. Without a record of the discussion he relies on his usual practice. Ahpra accepts that his usual practice is reasonable but notes the gap, and the matter closes with advice. He adds a brief consent line to every manipulative technique.

The tempting line

A GP reviewing his notes after a complaint about a missed fracture sees he did not document examining the wrist, though he believes he did. He considers adding a line, but instead seeks advice, states in his response that the examination is not recorded, describes what he recalls and his usual practice, and explains the template change he has made. The matter is managed as a clinical concern only.

The AI-drafted examination

A practitioner reviewing an AI scribe draft notices it records a normal chest examination in a consultation about a skin rash. She deletes the line, records her actual findings and reports the issue to her practice's AI governance lead. Had she signed it unchecked, the false finding would have been hers.

Documentation is one of the most improvable areas of practice, and improvement is easy to evidence: a revised template, a habit of writing notes before the next patient, and a before-and-after audit. A course can help you understand what each standard requires and why, and our courses include a reflective account you can keep. Our courses are independent and are not accredited and not approved by Ahpra or any National Board, and no course can guarantee any regulatory outcome. If education is part of an undertaking or condition, check with Ahpra that a course is acceptable. If you have received a notification, get advice from your indemnity insurer, MDO or lawyer and read our notification help guide.