Medicare requires an adequate and contemporaneous record of every service, and the Medical Board of Australia asks for records made at the time of care or as soon as possible afterwards. Neither sets a format.
A worked note
A worked progress note, element by element Element The entry as written Presenting problem 62-year-old woman, three weeks of chest tightness on exertion, settling within five minutes of rest. Nil pain at rest, nil nocturnal symptoms. Relevant history Ex-smoker, 20 pack-years, ceased 2019. Father had a myocardial infarction at 58. Current medication: perindopril 5 mg daily. Examination BP 148/86 seated, both arms. HR 78, regular. Dual heart sounds, no murmur. Chest clear. No peripheral oedema. Investigations to hand ECG today: sinus rhythm, no ST change. Bloods of 14 August: LDL 3.8 mmol/L, HbA1c 5.4 per cent, eGFR above 90. Assessment Stable angina, intermediate pretest probability on age, sex and risk factors. Musculoskeletal chest pain and reflux considered. No features of an acute coronary syndrome. Plan CT coronary angiogram, referral sent today. Atorvastatin 40 mg nocte started; myalgia and liver function monitoring explained. Review with results in three weeks. Advice given Told to call 000 for chest pain at rest, or chest pain with sweating or breathlessness. Patient repeated the advice back. Author and time Dr [name], consultant cardiologist. Entered 5 September 2026, 10:20.
What each element carries
What each element carries, and what a reviewer checks Element What it carries What a reviewer checks Presenting problem The complaint, how long it has run, and what brings it on or settles it. Whether the episode can be placed in time without asking the patient again. Relevant history Risk factors, comorbidities and current medication with doses. Whether the assessment accounts for the risk the history carries. Examination Measured values, and the findings that were looked for and absent. Whether the examination on the page supports the diagnosis reached. Investigations to hand Results quoted with their dates and units. Whether the numbers used in the reasoning appear in the record. Assessment The working diagnosis, the differential considered, and what was excluded. Whether the reasoning is written down or has to be inferred. Plan Investigation ordered, drug and dose, counselling given, and the review interval. Whether the next clinician can act on the entry without a phone call. Advice given The safety-netting words used, and the patient's response to them. What the patient was told, when that account is later disputed. Author and time Who made the entry, their role, and when it was written. Whether the record was made at or close to the time of care.
Timing and later entries
An entry is made during the consult or straight after it.
A later addition is dated to the day it was written, and the original entry stays as it was.
Copying a previous consult forward carries its errors, and two identical entries a fortnight apart leave a reviewer unable to tell which findings were taken on the day.
The aurii draft
aurii records the consult and drafts a note from the transcript, in the template set up for that clinician.
Every draft uses your letterhead and section order, set once in your templates.
No. A clinician edits the draft against the consult and signs it.
No. A note carries the assessment, the plan and what was excluded, written after the conversation is interpreted.
Record-keeping periods are set by state and territory health-records law and by the practice's own policy. A practice can have its records deleted on request.
This is general information about clinical documentation, not clinical or legal advice.
