A paediatric note carries the parent's account, the child's words and the clinician's findings, and the attribution between them is checked at review.
Attribution in the draft
A paediatric note carries three sources: the account the parent gave, the words the child used, and the clinician's examination findings. A fever reported at home and a temperature measured in the room are separate entries.
An examination carried out in silence leaves nothing in the audio, so the finding is spoken or typed into the draft.
Where several people talk across each other, a sentence can be assigned to the wrong speaker, so attribution is checked line by line at review.
Where an interpreter speaks for a parent, the account belongs to the parent and their involvement is recorded in the note. Consultations with interpreters.
Consent when the patient is a child
A young person with the capacity to consent to their own treatment, the mature minor position in Australian law, can consent to capture without a parent. Otherwise the parent or guardian consents. Where an adolescent is seen alone, the consent question is put to them.
Recording law differs between states and territories, and the strictest of them require the consent of every person recorded.
Measurements and immunisations
Weight, length and head circumference are charted in the practice software, and immunisations recorded there flow to the Australian Immunisation Register. aurii does not write into Best Practice, MedicalDirector or Genie.
A measurement spoken in the consult reaches the draft and is checked against the charted value.
Sensitive disclosure and safeguarding
Health practitioners are mandated reporters of suspected child abuse and neglect in most Australian jurisdictions, with the scope and the threshold set by each state and territory. A safeguarding note records what was seen and what was said, in whose words, close to the consult it describes.
A parent with access to the child's record may later read an adolescent psychosocial screening note. Where part of a consult should not be recorded, that part of the note is typed.
The treating clinician remains responsible for the clinical content. Clinical safety.
Retention for a patient under 18
State and territory health-records law sets the retention period, and information collected while the patient was under 18 is held until that patient turns 25. The obligation sits with the practice and outlasts the subscription.
Deletion runs on request. What is deleted and what the practice keeps. Consult audio has its own deletion schedule, separate from the signed note. Audio retention and deletion.
aurii in a paediatric consult
aurii captures a paediatric consult with consent and drafts the note in the practice's templates. Referral letters to a paediatrician, a school or an allied health provider are drafted from the same consult. The clinician corrects attribution and signs. aurii does not diagnose, does not write into practice software, and does not update the growth chart or the Australian Immunisation Register. On the Australian App Store for iPhone and iPad, and at app.aurii.com.au in a browser. Get the app.
For a young child, the parent or guardian consents on the child's behalf. A young person with the capacity to consent to their own treatment can consent to capture without a parent. Consent can be withdrawn part-way through the visit, and the note for the rest of the consult is typed.
No. Measurements and immunisations are entered by the clinician in the practice software, and immunisation encounters flow to the register from there. aurii drafts the note around that data. Integrations.
State and territory health-records law sets the period: seven years from the last entry for an adult, and, for information collected while the patient was under 18, until that patient turns 25. What is deleted and what the practice keeps.
This is general information for Australian paediatric and general practice teams, not clinical or legal advice.