Consent covers the audio of one session and can be withdrawn at any point. The risk assessment, the safety plan and the formulation are written by the clinician, and the draft is edited and signed before anything leaves.
The record and the process note
The draft carries the concerns raised, the risk screen, the agreed plan and the next appointment. The clinician adds the safety check made after capture ended, cuts what the file does not need, and signs.
The clinical record and the clinician's process notes are both health information about an identified client, and an access request can reach either.
A practice decides which of the two it drafts toward. Drafting the clinical record keeps verbatim disclosure out of the automated path.
- In the record: presenting concern, risk screen, formulation, agreed plan, progress since the last session
- In a process note: hypotheses, supervision questions, observations about the therapeutic relationship
- In neither: verbatim disclosure that serves no clinical purpose
Consent in mental health work
Health information is sensitive information under the Privacy Act 1988 (Cth), and the Australian Privacy Principles set a higher test for collecting it. Consent to record covers one act: audio captured in the room so a note can be drafted from it. Agreement given at intake does not cover a later session that turns to new material.
Re-asking at the start of a course of sessions, and when the material shifts, keeps that consent current. Consent can be withdrawn at any point in a session, and the client does not have to give a reason. A client who declines is documented by hand. The wording, and a sheet to hand out, sit in consent for AI scribes.
Risk disclosures
A disclosure of suicidal ideation, self-harm, family violence or a child safety concern is responded to in the room, at the time. The risk assessment, the safety plan and any decision to contact a carer, a service or a reporting line are written by the clinician.
Mandatory reporting obligations differ by state and territory and by registration. The treating clinician remains responsible for the clinical content. Clinical safety.
Sessions not to capture
A recording of a court-ordered or medico-legal assessment adds material that can be produced in a hearing. One refusal ends a group session.
- No consent given, or consent withdrawn during the session
- Court-ordered assessments and medico-legal reports
- Group sessions where any participant declines
- A third party in the room who has not been asked
- A client in acute distress
Storage, access and deletion
Mental health files are held for long periods under state health records law and the registration board's record-keeping standards.
aurii does not upload to My Health Record.
aurii in a psychology session
aurii records a consented session and drafts the progress note, along with any letter to the referring practitioner.
The audio is transcribed, and the draft is built from that transcript. What reaches the clinical file is the note the clinician edits and signs. What is deleted and what the practice keeps.
Yes. Consent can be withdrawn at any point, without a reason. The clinician ends the capture and writes the remainder of the session by hand.
The clinical record. That keeps verbatim disclosure out of the automated path and leaves the process note as a separate act the clinician writes.
This article is general information about clinical documentation practice, not clinical, legal or professional advice; individual obligations depend on your registration board, jurisdiction and practice context.