The interval that counts runs from the consultation to the signature. Review means reading the draft against the consultation, correcting it, adding what the scribe could not hear, and signing last.
Where the obligation sits
The Medical Board of Australia's Good medical practice requires doctors to keep clear, accurate and up to date clinical records that report the relevant details of each consultation and are held securely. The Nursing and Midwifery Board's professional standards carry an equivalent record-keeping requirement, and the shared Code of conduct used by several other National Boards does the same.
Ahpra and the National Boards name no documentation tool. The requirement attaches to the practitioner who provided the care and to the record they finalise, whether it was typed, dictated or drafted by software.
Obligations carried by the practitioner
- An accurate account. A scribe records what was spoken aloud, so a silent observation is absent from the draft until it is added.
- A contemporaneous entry. The record is made at the time of the consultation or as soon as practicable afterwards. The interval that counts runs to the signature.
- Identification of the author. Where software drafts and a practitioner signs, the signing practitioner is the author.
- Security of the source material. Sending a consultation recording to a third party is a disclosure of health information, and the practice stays accountable for how the recipient handles it.
- Retention. State and territory health-records law sets the period, commonly seven years from the last entry for an adult and, for a patient who was a child, until the age of 25. Closing a software account does not end it.
- Production on request. A patient, a court, Ahpra or a medical defence organisation can request the record, and drafting history held inside the scribe needs a route out.
Review before signing
The full draft is read against the consultation, corrected, added to where the scribe could not hear, and signed last. The signature is the act the professional standards attach to.
- Medication names and doses. Similar-sounding names and transposed numbers survive transcription intact.
- Laterality and site. Left and right, and the level, vessel or joint named in a procedure.
- Negative findings. A clear chest or an absent red flag reaches the note only if it was said aloud.
- Attribution. A comment from a parent, carer or interpreter can arrive in the draft as the patient's own words.
- The plan. Follow-up interval, referral urgency and safety-netting advice, which a draft can broaden.
Consent and the recording
A consultation recording is sensitive information under the Privacy Act 1988 (Cth) and the Australian Privacy Principles. Collecting it requires consent to the recording, which is separate from consent to treatment. The OAIC publishes guidance for health service providers on collection and on what patients must be told.
Record consent as its own dated event. Wording for that conversation, and what to log.
aurii and the signed record
aurii drafts the note and the correspondence, and stops at the draft. The treating clinician remains responsible for the clinical content. Clinical safety.
The draft, the edits made at review and the signature that closed it are all in the audit log. Every action a practice user takes is written to a hash-chained audit log. How the chain works.
The registered practitioner who reviews and signs it. Ahpra and the National Boards attach record-keeping obligations to the practitioner who provided the care, and the standards draw no distinction between a note that was typed, dictated or drafted by software.
No. A contemporaneous, clinically relevant record supporting the item billed is still required. The record is the signed note, so the interval that matters runs from the consultation to the signature.
State and territory health-records law sets the period, commonly seven years from the last entry for an adult and, for a patient who was a child, until the age of 25. That obligation sits with the practice and continues after a software subscription ends.
This article is general information about record-keeping practice and does not constitute legal, clinical or regulatory advice for any particular practice.