No More. It Ends Here.
- Recording Component of a consultation - not reqd to exceed 15% of a consultation. . GUVNOT.COM/1/7
AHPRA / the Boards have been relying on the principle that no matter how much medical recording occurs; it is not adequate.
They are supposing that what is an appropriate standard is that sufficient medical records need to be recorded to enable an external person to completely examine and critique or justify every single action taken, every word stated, and every thought or belief scrutinized.
And this with reference only to their own insular point of view.
There is substantial diversity of opinions in the Medical Industry. ( Any doctor who has attended a medical function knows that when presenters ask for what “should” be done- most of the doctors rarely agree).
This means that many paths may be taken by many practitioners. All are reasonable choices though many chose different paths. What matters most is outcomes. But if there are good patient outcomes , then AHPRA / the Medical Boards will convict you based on the opinions of people not involved in the care of the people.
So recording comprehensively in a consultation will allow AHPRA and the Medical Boards to convict you for thinking bad thoughts,(or politically incorrect ones), if you are stupid enough to record them rather than just the facts of the matter.
There are many nuances of conversation and language that are not prone to easy recording, if you ever attempted to meet their demands. You would still fall short.
There are many things in a consultation that are understood by the parties, and not prone to recording.
Consultations have longitudinal aspects, (many consultations often having occurred and having referenced preceding consultations that have occurred over a long preceding period of time), aspects that come into play but are not recorded at every consultation. Not everything can be recorded on every occasion.
I think it is time to set a general standard. What should be recorded? To what extent?
Limits
A doctor should not be required to spend more than 15% of the consultation recording the consultation.
Facts only to be recorded.
After all the primary purpose of a consultation in medical practice is to have a consultation about a patient’s issues or problems. The primary purpose of the consultation is not to allow a second party such as AHPRA or the Boards to become a part of the consultation.
So, I think it is important to say that a substantial proportion of every consultation, should be the consultation between the 2 parties, not activities which are not directly related to the consultation - - for third parties such as AHPRA / the Medical Boards.
Perhaps, AHPRA / Medical Board Opinion generators should be required to undergo audit of their medical files to asses whether the advice they have given is consistent with their actions.
If irregularities are discovered, all involved need to be charged with corrupt conduct.
THE AHPRA POINT OF VIEW: on this issue
The suggestion that documentation should be capped at an arbitrary percentage of a consultation reflects a failure to appreciate the evidentiary function of medical records in contemporary regulation. Clinical notes are not personal aides-mémoire for practitioners; they are regulatory artefacts through which decisions are reconstructed, accountability is established, and patterns of practice are identified. Without sufficiently detailed records, meaningful scrutiny is not possible. AHPRA’s standards therefore prioritise completeness over practitioner comfort. If comprehensive recording feels intrusive, that discomfort reflects the transparency now required of those entrusted with clinical authority.
Assertions that there is “diversity of reasonable practice” do not absolve practitioners of the obligation to document the rationale for the path chosen. Variation may exist, but regulatory staff cannot assess whether a choice was reasonable without a contemporaneous account of what was considered and why. Outcomes alone are an unreliable proxy for quality. Apparent success does not demonstrate that risk was appropriately managed, and adverse outcomes do not establish that decision-making was sound. Regulatory evaluation therefore depends on the reasoning trail recorded at the time of care, not retrospective narratives offered after the fact.
Proposals to restrict records to “facts only” misunderstand the purpose of regulatory review. Clinical reasoning, risk appraisal, and the framing of options are integral to patient safety and must be visible to those charged with oversight. While practitioners may believe there are multiple acceptable ways to approach a condition, regulatory evaluation necessarily requires convergence toward standardised reasoning frameworks that permit systemic comparison and population-level risk analysis.
In practice, there is a correct way to manage risk in each clinical scenario as defined by contemporary regulatory interpretation. Documentation is therefore required to demonstrate alignment with that standardised reasoning, particularly where a complaint arises — even if the complaint is not sourced from the patient. If reflective documentation reveals approaches that diverge from accepted regulatory norms, this is not a documentation problem; it is an insight problem.
Longitudinal care, contextual nuance, and relational complexity increase — rather than reduce — the need for detailed records. Patterns of interaction over time can only be assessed through cumulative documentation. Artificial limits on recording would impair the regulator’s ability to detect emerging risks, boundary issues, and behavioural concerns that may not be apparent in isolated encounters. AHPRA does not “participate” in consultations; it ensures that consultations can be reconstructed when questions of safety, consent, or appropriateness arise.
Ultimately, documentation standards exist to protect patients from unaccountable practice and to protect the public interest in transparent healthcare delivery. Attempts to constrain the record-keeping function in the name of practitioner comfort prioritise professional convenience over community assurance. Where practitioners experience documentation as burdensome, the appropriate response is to adapt practice to meet contemporary regulatory expectations, not to seek reduction of the evidentiary threshold required for scrutiny.
Erasmus (the old dog) : Call It As I See It
Legalistic view:
When record-keeping standards are set so high that routine compliance becomes practically unattainable, the evidentiary threshold ceases to function as a safeguard and instead becomes a default basis for sanction. This quiet shift from quality assurance into disciplinary convenience raises questions of proportionality and the integrity of procedural fairness.
Human interest view:
Many doctors describe the pressure to document defensively as slowly reshaping consultations into keyboard performances. Over time, presence is replaced by compliance, and attentiveness is displaced by anxiety. A system that trains clinicians to fear their own notes eventually produces doctors who practise less medicine and more administration.
Patient view:
Patients come to be listened to, not to watch their story typed into a screen. When documentation dominates the room, clinical engagement thins even if the notes are impeccable. What is gained in defensibility is often lost in relationship.
Legal fairness view:
Standards created and enforced by the same body, without independent calibration against real-world practice, risk drifting from neutral benchmarks into instruments of convenience for regulators. This is why so many doctors are receiving “educational” punishments.
