Ethics and professionalism CPD for health practitioners in Australia [email protected]
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Online course · Australia

Professionalism in Documentation and Record-Keeping

Accurate, Timely and Defensible Clinical Records

  • About 2 hours
  • 15 scenario questions
  • Reflective account
  • Certificate of completion
  • Online, self-paced

About this course

Clinical records are written for the next clinician, the patient, an auditor and sometimes a court, often years later. This course shows practitioners what a good record contains and how to keep records that are accurate, timely and defensible in modern practice.

The course explains the purposes of a clinical record, what the Code and Ahpra expect, how documentation features in notifications and records as part of professional identity. It then covers core content, structure and clinical reasoning, consent, advice and safety-netting, and respectful language.

Timeliness lessons cover contemporaneous records, late entries and addenda, correcting errors and why records must never be altered after the event. Modern practice lessons cover shared records and handover, telehealth, phone calls and messages, templates, copy-forward and auto-text, and AI scribes and generative AI.

Later sections explain the laws that govern health records, retention and practice closure, Medicare and the Professional Services Review, referrals, reports and My Health Record, and what to do when your records are requested, writing statements from records, auditing your own records and building lasting habits.

What you will learn

  • Explain who reads clinical records, for what purposes, and why poor notes feature in so many notifications
  • Measure your documentation against the Code and Ahpra's published expectations
  • Record what you found, what you thought and what you did, with more detail where risk is higher
  • Show the advice, consent and safety-netting you gave, in neutral and respectful language
  • Add late entries and fix mistakes openly, and never change a record after the fact
  • Keep shared records, handover notes, phone and telehealth entries and messages complete
  • Check template and AI-generated text before it becomes part of the record
  • Meet retention and Medicare record rules and audit a sample of your own notes

Who this course is for

  • Practitioners in every profession and setting
  • Practitioners using templates, copy-forward or AI scribes
  • Practitioners who bill Medicare or other funders
  • Practitioners asked to provide records or statements
  • Supervisors teaching documentation to students

How the course works

  1. Enrol online and the course appears under My Courses in your Probity Courses account, ready to open on a computer, tablet or phone.

  2. Work through 6 sections and 24 short lessons in order, at your own pace. Your place is saved in the browser you use, so you can stop and come back.

  3. Use the key points, scenarios and reflection prompts in each section, and write your own notes as you go; they stay with your course pack.

  4. Finish with a 15-question final assessment. You need 12 correct answers (80%) to pass, and you can retake it after a short pause if needed.

  5. Write your reflective account, submit the short feedback form and your completion is recorded. Download a certificate of completion stating the estimated learning time (about 2 hours); record the time you actually spend.

Course content

7 sections · About 2 hours · 15-question final assessment

1Why Clinical Records Matter4 lessons
  • The Purposes of a Clinical Record
  • What the Code of Conduct and Ahpra Expect
  • Documentation and Notifications
  • Records as Part of Professional Identity
2What a Good Record Contains4 lessons
  • Core Content of Every Entry
  • Structure and Clinical Reasoning
  • Consent, Advice and Safety-Netting
  • Objective, Respectful and Culturally Safe Language
3Timeliness, Corrections and Late Entries4 lessons
  • Contemporaneous Records
  • Late Entries and Addenda
  • Correcting Errors
  • Never Alter Records After the Event
4Records in Modern Practice: Teams, Telehealth, Templates and AI4 lessons
  • Shared Records, Handover and Team Documentation
  • Telehealth, Phone Calls and Messages
  • Templates, Copy-Forward and Auto-Text
  • AI Scribes and Generative AI
5Legal Frameworks: Retention, Access and Medicare Requirements4 lessons
  • The Laws That Govern Health Records
  • Retention, Ownership and Practice Closure
  • Medicare and the Professional Services Review
  • Records That Travel: Referrals, Reports and My Health Record
6Records Under Scrutiny and Improving Your Own4 lessons
  • When Your Records Are Requested
  • Writing Statements and Reports From Records
  • Auditing Your Own Records
  • Building Habits That Last
7Conclusion, Final Assessment and Reflection4 lessons
  • Conclusion and key points
  • References and quick-reference guide
  • Final assessment (15 questions, 80% pass mark)
  • Your reflective account

Assessment and certificate

  • Certificate of completion stating the estimated learning time (about 2 hours); record the time you actually spend.
  • A written reflective account you can keep with your CPD records.

Questions about this course

Can I add to a note after the consultation?

Yes, as a clearly dated late entry or addendum that shows when it was made. What you must never do is alter or backdate a record so it appears contemporaneous.

Is it safe to use an AI scribe?

It can be, with patient consent, privacy safeguards and careful checking of every note it drafts. The note is still yours once you accept it. The course explains the risks.

How long must I keep records?

Retention periods are set by state and territory law and differ for adults and children. The course explains the principles and where to find the rules for your jurisdiction.

Does the course help me audit my own notes?

Yes. A lesson guides you through a simple self-audit you can repeat.

Can I count this course towards my CPD?

That is your call under your Board's CPD standard: you choose activities that match your scope and the learning needs in your plan. If this course fits, file the certificate of completion, record the time you actually spend and note one change you will make in practice.

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