The department's systems hold the timing skeleton of a presentation, and an audio draft carries the reasoning between those times. Each assessment belongs in the record as its own timed entry under its own author, and parts of a shift are not recorded at all.
Where the times come from
The triage entry, the observation chart, the ambulance handover minute, the ECG and the pathology collection times sit in the department's own systems and are never said out loud, so the timing skeleton comes from the record system and an audio draft carries the reasoning between those times.
An Australasian Triage Scale category 2 sets a maximum wait of ten minutes for medical assessment.
What each assessment has to carry
Explain the capture before starting it, and record the answer in the note.
The differential considered and excluded, and the reason a test was not ordered, are what a later reader looks for.
A clinical claim that the patient is unchanged rests on each assessment carrying its own time and author, and a tool that merges three visits into one narrative removes the intervals it rests on. Give any tool three short captures of the same patient and see whether it produces three timed entries or one paragraph.
When the assessment is interrupted
A capture left running after the clinician is called away records the resuscitation, the handover, the phone call to the psychiatry registrar, and a family being told that someone has died, none of it consented to.
- whether capture pauses when the device locks or the app loses focus, and whether it stops on its own after a period of inactivity
- whether stopping takes one action that works with gloved hands and without unlocking the device
- what happens to audio captured in error, how quickly it is deleted, and whether the deletion is itself logged
Settings where capture stays off
The legal basis for treating a patient who cannot consent does not extend to recording them. Urgent treatment without consent rests on the common law principle of necessity and on the emergency provisions in state and territory guardianship and medical treatment legislation, and it authorises what is necessary for the patient's care. A recording is neither treatment nor necessary to it. Recording a private conversation also engages state and territory surveillance devices legislation, which is not uniform across the country.
A patient's legal status can change during a stay, and the status that governs is the one at the time of the assessment. The exclusion list belongs in local procedure and registrar induction.
- the resuscitation bay, where nobody present can consent and alarms and several voices wreck the audio; a resuscitation is documented on a timed structured form kept by a designated scribe
- any patient whose capacity is impaired by intoxication, delirium, a post-ictal state, sedation or unconsciousness
- assessments of a patient detained under state or territory mental health legislation
- forensic and sexual assault examinations, and patients under police guard
- conversations with a family after a death
Registrar assessment and consultant review
A consultant review is a clinical event with its own time and its own author. A draft assembled from a shift of audio attributes everything to whoever signs it, and nothing on the face of the note looks wrong.
The Medical Board's Good medical practice code expects records that are accurate, up to date, legible and written so that another practitioner can understand them, and a record that cannot say which clinician made an assessment fails that test. A consultant should be able to see and correct any entry that carries their name.
The discharge letter
Four things belong in the letter to the GP: what was excluded and by what means, the medication changes, the return precautions in the words they were given, and what is still pending, each pending item named with the clinician who will act on it.
An entry reading discharge advice given tells a later reader nothing. The note needs who received the advice, whether they were in a state to take it in, and the circumstances they went home to.
aurii in an emergency department
aurii captures an assessment as its own session and drafts a structured note from what was said at the bed. Three bedside assessments across one presentation produce three drafts. The clinician reconciles each draft against the times the department's systems hold before signing.
Nothing leaves aurii until a clinician signs it. Clinical safety. The clinician who signs a draft is its author, so a registrar's assessment carries the registrar's name and a consultant's review carries the consultant's, and hospital policy on senior review and countersignature applies to it unchanged.
Signed letters go out over Medical Objects. Integrations.
It does not, and the relative at the bedside cannot give it for them unless their authority as a substitute decision-maker has been established. The legal basis for treating a patient who cannot consent covers what is necessary for their care, and a recording is neither. Leave the tool off while capacity is impaired, ask again if the patient clears later in the stay, and capture the reassessment.
It captures the times people say out loud. The triage entry, the observation chart trend, the pathology collection times, the repeat ECG and the minute the ambulance handed over sit in the department's own systems, so the timing skeleton comes from there. Ask any vendor whether a time in a draft comes from the moment of capture or the moment of signing.
Each assessment is its own timed entry, signed by the clinician who made it. Watch for a tool that merges a shift of audio into one note attributed to whoever signs last.
This is general information about documentation in emergency medicine. It is not clinical or legal advice.