Every clinician involved in a patient's care keeps a record of their own part, and the referrals, reports, letters and plans that move between them are documents derived from those records. Record-keeping obligations stay with each registrant, whoever convened the team.
Who signs what
The organisation holding the record controls it, and Ahpra attaches record-keeping obligations to each registrant personally, which joining a team does not move to whoever convened it.
A drafted document has no professional author until a named clinician reviews it, corrects it and signs it into their own record.
Who signs each document a team produces, and what the other participants record Document Who signs it What the other participants record Case conference summary The clinician who convened the conference, usually the coordinating GP. A short entry in their own system: attendance, the decisions affecting their part of the care, and a reference to the summary. Chronic condition management plan and its reviews The GP who prepares or reviews the plan. Each contributing provider records what the plan asked of them and what they delivered under it. Allied health or specialist report back The clinician of that discipline who did the assessment. The referring clinician files the report against the patient and records any change it makes to the plan. Referral or letter to another clinician The clinician whose name it goes out under. The receiving clinician records the referral when it is accepted, and records the reply sent back.
Case conference records
A conference can attract MBS case conference items when the requirements are met, and the items set out what the record must show, so read the current item descriptor on MBS Online before claiming.
A summary is usable when a colleague who was absent can act on it.
- the date and who took part, with each participant's name, discipline and organisation
- the patient, and the conditions or problems discussed
- the decisions made and the goals agreed, in terms specific enough to check later
- each action, with a named owner and a timeframe
- what the patient or carer was told, and how their views were taken into account
Care plans across disciplines
A chronic condition management plan records the patient's goals, the disciplines involved and what each contributor will do, and allied health providers treating under the plan report back to the referring GP.
A review booked on a full day shrinks to a date change unless the plan carries a named owner and a review date held in the recall system. A goal in general terms cannot be assessed at the review, so each is phrased against something checkable in the record. Incoming reports need one filing route against the patient, or they sit in a scanning queue.
Sharing between systems
Duplication starts when the same content is maintained by hand in more than one place: the clinical system, a shared spreadsheet, a document emailed to a case manager.
Corrections are made in the primary record and the document re-issued from it, with a note of what was sent, to whom and when.
Share what answers the question asked: the relevant history, current medicines and any risks. Sending the full record to every provider widens the privacy exposure.
What aurii does in a case conference
aurii records the case conference with the consent of everyone present, then drafts the note and the letters from that recording.
Nothing leaves aurii until a clinician signs it. Clinical safety.
Everyone being recorded has to agree, and that includes the other clinicians present as well as any patient or carer. There is a longer note on consent for ambient recording.
The clinician who convened the conference, usually the coordinating GP. Every other participant records attendance, the decisions affecting their part of the care, and a reference to the summary in their own system.
Signed letters go out over Medical Objects. Integrations.
This is general information about documentation in team-based care. It is not clinical or legal advice.