CL2. Clinical Documentation

Accurate records, valued practice
“When you undervalue what you do, the world will undervalue who you are.” — Oprah Winfrey

Policy Purpose

To ensure all documentation across Trust Children and ReadyStepGrow is accurate, timely, and professional. Documentation underpins safe, high-quality care, supports funding compliance, and preserves the integrity of the clinical record. This policy also clarifies the distinction between clinical notes and service records, recognising that both exist within Cliniko but serve different purposes.

Policy Statement

We commit to maintaining documentation that is clear, accurate, respectful, and aligned with professional standards, funder requirements, and △△D policies. Clinical notes remain child-focused and therapy-oriented. Administrative, funding, and legal matters are documented separately in service records.

All records must uphold confidentiality in line with the Confidentiality & Consent Policy. We write with integrity, impartiality, and respect for children, families, and colleagues.

See the Artificial Intelligence (AI) Use Policy (Supporting Policy 11) for guidance on safe and approved use of AI in clinical documentation and drafting.

Policy Details

Clinical Notes

Clinical notes document the therapeutic work and include:

• Assessments
• Therapy plans (clinical and family-friendly versions)
• Session notes
• Progress and review reports

Clinical notes must:

• Link clearly to therapy plan goals
• Use professional, objective, and child-focused language
• Apply the ICF framework where relevant (functions, activities, participation, contextual factors)
• Meet funder and regulatory requirements (NDIS, Medicare, and other third parties)

Service Records

Service records capture non-clinical information, such as:

• Administrative communication with families (scheduling, cancellations, fee discussions)
• Funding-related correspondence (NDIS portal issues, Medicare claims)
• Legal or consent documentation not related to therapy content
• Operational notes relating to service delivery

Service records must exclude:

• Clinical reasoning or therapy content
• Judgements about family dynamics

Maintaining this separation ensures:

• Clinical documentation remains professional and impartial
• Administrative records are accessible without contaminating the clinical record
• Subpoenaed records reflect only the professional role of the clinician

Therapy Plans

Therapy plans are developed in line with the Therapy Plan Policy and include:

• Clinical version – ICF-coded, used for multidisciplinary communication and funding reporting
• Family-friendly version – strengths-based, plain language

Session Notes

• Every session must be documented in the approved format.
• Notes must link to one or more therapy plan goals.
• Progress, barriers, and strategies must be recorded in relation to goals.
• Notes must be completed as soon as possible and no later than 48 hours after the session.

Reports

Reports (progress, review, NDIS, school, medical) must be drawn directly from session notes linked to plan goals.

Reports must use professional language, balancing strengths-based and deficit-based documentation depending on the audience (e.g., plain language for families, ICF-coded for funders).

Accountability

• Each staff member is responsible for completing their documentation accurately and within timeframes.
• Documentation quality is supported through regular supervision.
• Supervisors guide and mentor staff where gaps are identified, ensuring support rather than punitive measures.
• When responsibilities are not met (e.g., delayed, missing, or inconsistent notes), these must be raised promptly so they can be resolved constructively.

Responsibilities by Role

Clinicians

• Complete all assessments, therapy plans, session notes, reviews, and reports within required timeframes.
• Apply the ICF framework where appropriate.
• Review and co-sign therapy assistant notes.

Therapy Assistants

• Document all delegated activities in session notes.
• Submit notes for clinician review and co-signing.
• Provide observational feedback in supervision.

Administrative Staff

• Record scheduling, billing, cancellations, and funding issues in service records only.
• Maintain confidentiality when handling family information.

How to Raise a Concern

If staff identify issues with documentation (e.g., missing, inaccurate, or delayed records), they must:

1. First raise the concern directly with the staff member involved, where appropriate.
2. If unresolved, escalate to the relevant supervisor.
3. Supervisors will work collaboratively with staff to provide support, coaching, and systems to address the concern.
4. Concerns that may impact child safety must be immediately raised under the Child Safety Policy.

Related Policies and How They Connect

• Child Safety Policy – ensures documentation supports safe, child-centred care.
• Confidentiality & Consent Policy – protects privacy, consent, and use of information.
• Therapy Plan Policy – guides creation of both clinical and family-friendly plans.
• Governance & Quality Policy – outlines how this policy is monitored, reviewed, and continuously improved.
• Artificial Intelligence (AI) Use Policy – sets boundaries and safe practices for AI in clinical documentation.

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Document Control: v1.1 · Created: Aug 2025 · Updated: Sep 2025 (added AI cross-reference; clarified documentation standards) · Review: Annual (Jan 2026) · Owner: △△D Pty Ltd

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