{"id":33570,"date":"2026-07-06T15:52:46","date_gmt":"2026-07-06T15:52:46","guid":{"rendered":"https:\/\/healthcareethicscourses.com\/au\/?page_id=33570"},"modified":"2026-07-12T18:02:58","modified_gmt":"2026-07-12T18:02:58","slug":"clinical-documentation-record-keeping","status":"publish","type":"page","link":"https:\/\/healthcareethicscourses.com\/au\/clinical-documentation-record-keeping\/","title":{"rendered":"Clinical Documentation &#038; Record Keeping"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"33570\" class=\"elementor elementor-33570\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-7c5607e e-con-full e-flex e-con e-parent\" data-id=\"7c5607e\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-e300bac elementor-widget elementor-widget-html\" data-id=\"e300bac\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<!-- Healthcare Ethics Courses \u2014 Osteopathy Board article \u2014 paste into an Elementor Custom HTML block. 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aria-hidden=\"true\">&rsaquo;<\/li>\r\n      <li><a href=\"\/au\/knowledge-support\/\">Osteopathy Board<\/a><\/li>\r\n      <li class=\"sep\" aria-hidden=\"true\">&rsaquo;<\/li>\r\n      <li aria-current=\"page\">Clinical Documentation and Record Keeping for Osteopaths<\/li>\r\n    <\/ol>\r\n  <\/nav>\r\n\r\n  <header class=\"head wrap\">\r\n    <h1>Clinical Documentation and Record Keeping for Osteopaths<\/h1>\r\n    <div class=\"meta\">\r\n      <span>8 min read<\/span>\r\n      <span class=\"dot\" aria-hidden=\"true\">&bull;<\/span>\r\n      <span>Last updated June 2026<\/span>\r\n    <\/div>\r\n    <p class=\"lead\">Good records underpin safe osteopathic care and protect you if your practice is questioned. This guide sets out what a good osteopathic record contains \u2014 including the consent and chaperone details that matter for hands-on treatment \u2014 and the privacy, retention and access rules to follow.<\/p>\r\n  <\/header>\r\n\r\n  <div class=\"takeaways wrap\">\r\n    <h2>Key takeaways<\/h2>\r\n    <ul>\r\n      <li>The shared <strong>Code of conduct<\/strong> requires accurate, up-to-date, factual, objective and legible records.<\/li>\r\n      <li>Record examination findings and clinical reasoning, including pertinent negatives.<\/li>\r\n      <li>Evidence <strong>consent<\/strong> for hands-on treatment and any <strong>chaperone<\/strong> offer.<\/li>\r\n      <li>Make entries contemporaneously and never alter a record after a concern is raised.<\/li>\r\n      <li>Records are health information \u2014 store securely and retain per state and territory law.<\/li>\r\n    <\/ul>\r\n  <\/div>\r\n\r\n  <div class=\"wrap\">\r\n    <h2>Why documentation matters in osteopathy<\/h2>\r\n    <p>Clear records underpin safe, coordinated osteopathic care and are your best protection if your practice is questioned. The shared <em>Code of conduct<\/em> requires accurate, up-to-date, factual, objective and legible records held securely. For hands-on practitioners, the record should also evidence the <strong>consent<\/strong> and communication that surround physical treatment.<\/p>\r\n\r\n    <h2>What a good osteopathic record contains<\/h2>\r\n    <ul>\r\n      <li>Presenting complaint, relevant history, medications and red-flag screening.<\/li>\r\n      <li>Examination findings, including pertinent negatives.<\/li>\r\n      <li>Working diagnosis and clinical reasoning.<\/li>\r\n      <li>The treatment provided, techniques used, and the patient&#8217;s response.<\/li>\r\n      <li>Consent for treatment \u2014 especially involving sensitive regions \u2014 and any <strong>chaperone<\/strong> offer.<\/li>\r\n      <li>Advice, review plan, and any referral or safety-netting.<\/li>\r\n    <\/ul>\r\n    <aside class=\"note\"><p>Documenting consent and any chaperone offer is not defensive box-ticking \u2014 it is evidence that you practised safely and respected the patient&#8217;s autonomy.<\/p><\/aside>\r\n\r\n    <h2>Contemporaneous and unaltered<\/h2>\r\n    <p>Make entries at or near the time of care; never alter a record once a concern arises. Corrections should be transparent, dated and never obscure the original \u2014 amended notes undermine the credibility that good records provide.<\/p>\r\n\r\n    <h2>Privacy, retention and access<\/h2>\r\n    <p>Osteopathic records are health information and must be stored securely under the Australian Privacy Principles. Retention periods are set by state and territory law \u2014 generally at least seven years from the last entry for adults, and for children until a specified age \u2014 and patients have a right to access their records.<\/p>\r\n\r\n    <h2>Records and complaints<\/h2>\r\n    <p>If a concern arises, your records let you reconstruct the consultation and demonstrate sound, consented care. See our guides to <a href=\"\/au\/knowledge-support\/osteopathy-board\/professional-boundaries-osteopathy\/\">professional boundaries<\/a> and <a href=\"\/au\/knowledge-support\/osteopathy-board\/osteopathy-board-complaints-explained\/\">Osteopathy Board complaints<\/a>.<\/p>\r\n  <\/div>\r\n\r\n  <section class=\"courses wrap\">\r\n      <h2>Related CPD courses<\/h2>\r\n      <p class=\"intro\">Build the documentation habits this article describes with CPD for Australian practitioners:<\/p>\r\n        <a class=\"course\" href=\"https:\/\/healthcareethicscourses.com\/au\/courses\/documentation-for-healthcare-professionals\/\"><span class=\"course-tag\">CPD course<\/span><span class=\"course-name\">Documentation for Healthcare Professionals<\/span><span class=\"course-arr\"><svg viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"currentColor\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" aria-hidden=\"true\"><path d=\"M9 6l6 6-6 6\"\/><\/svg><\/span><\/a>\r\n        <a class=\"course\" href=\"https:\/\/healthcareethicscourses.com\/au\/courses\/confidentiality-in-healthcare-practice-2\/\"><span class=\"course-tag\">CPD course<\/span><span class=\"course-name\">Confidentiality in Healthcare Practice<\/span><span class=\"course-arr\"><svg viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"currentColor\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" aria-hidden=\"true\"><path d=\"M9 6l6 6-6 6\"\/><\/svg><\/span><\/a>\r\n        <a class=\"course\" href=\"https:\/\/healthcareethicscourses.com\/au\/courses\/professionalism-and-professional-standards-for-osteopaths\/\"><span class=\"course-tag\">CPD course<\/span><span class=\"course-name\">Professionalism and Professional Standards for Osteopaths<\/span><span class=\"course-arr\"><svg viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"currentColor\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" aria-hidden=\"true\"><path d=\"M9 6l6 6-6 6\"\/><\/svg><\/span><\/a>\r\n  <\/section>\r\n\r\n  <section class=\"siblings wrap\">\r\n    <h2>Continue the Osteopathy Board series<\/h2>\r\n        <a class=\"sib\" href=\"https:\/\/healthcareethicscourses.com\/au\/osteopathy-board-complaints-explained\/\">Complaints Explained<svg viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"currentColor\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" aria-hidden=\"true\"><path d=\"M9 6l6 6-6 6\"\/><\/svg><\/a>\r\n        <a class=\"sib\" href=\"https:\/\/healthcareethicscourses.com\/au\/professional-boundaries-in-osteopathy\/\">Professional Boundaries in Osteopathy<svg viewBox=\"0 0 24 24\" fill=\"none\" stroke=\"currentColor\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\" aria-hidden=\"true\"><path d=\"M9 6l6 6-6 6\"\/><\/svg><\/a>\r\n  <\/section>\r\n\r\n  <section class=\"faq wrap\">\r\n    <h2>Frequently asked questions<\/h2>\r\n      <div class=\"faq-item\"><h3>What should an osteopathic record include?<\/h3><p>The presenting complaint and history, red-flag screening, examination findings including pertinent negatives, working diagnosis and reasoning, treatment and response, consent and any chaperone offer, and the review plan.<\/p><\/div>\r\n      <div class=\"faq-item\"><h3>Why record consent and chaperone offers?<\/h3><p>For hands-on care near sensitive regions, documenting consent and any chaperone offer evidences that you practised safely and respected the patient's autonomy.<\/p><\/div>\r\n      <div class=\"faq-item\"><h3>How long must osteopathy records be kept?<\/h3><p>Retention is set by state and territory law \u2014 generally at least seven years from the last entry for adults, and for children until a specified age.<\/p><\/div>\r\n      <div class=\"faq-item\"><h3>Can I amend a record after a complaint?<\/h3><p>Only transparently \u2014 date the correction and never obscure the original. Altering notes undermines their credibility.<\/p><\/div>\r\n      <div class=\"faq-item\"><h3>Do patients have a right to their records?<\/h3><p>Yes. Under privacy law patients can generally access the health information held about them, subject to limited exceptions.<\/p><\/div>\r\n  <\/section>\r\n\r\n  <div class=\"wrap\">\r\n    <p class=\"disclaimer\">This article is general information for education and CPD purposes. It is not legal advice and does not create a practitioner\u2013adviser relationship. If you have received a notification, seek advice from your professional indemnity insurer, your union or professional association, or an independent lawyer experienced in health practitioner regulation. Healthcare Ethics Courses is an independent education provider and is not affiliated with, endorsed by, or acting on behalf of Ahpra or any National Board; regulator names are used for reference only.<\/p>\r\n  <\/div>\r\n\r\n  <script type=\"application\/ld+json\">\r\n{\r\n  \"@context\": \"https:\/\/schema.org\",\r\n  \"@graph\": [\r\n    {\r\n      \"@type\": \"Article\",\r\n      \"@id\": \"https:\/\/healthcareethicscourses.com\/au\/knowledge-support\/osteopathy-board\/clinical-documentation-record-keeping-osteopaths\/#article\",\r\n      \"headline\": \"Clinical Documentation and Record Keeping for Osteopaths\",\r\n      \"description\": \"Clinical documentation and record keeping for osteopaths in Australia - what a good record contains, consent and chaperone details, and privacy, retention and access rules.\",\r\n      \"inLanguage\": \"en-AU\",\r\n      \"datePublished\": \"2026-07-03\",\r\n      \"dateModified\": \"2026-07-03\",\r\n      \"author\": {\r\n        \"@type\": \"Person\",\r\n        \"name\": \"Dr Shehzad Iqbal\",\r\n        \"jobTitle\": \"Founder, Healthcare Ethics Courses\",\r\n        \"description\": \"MRCS, MRCGP, PG Cert Healthcare Law & Ethics (University of Dundee)\"\r\n      },\r\n      \"publisher\": {\r\n        \"@type\": \"Organization\",\r\n        \"name\": \"Healthcare Ethics Courses\",\r\n        \"url\": \"https:\/\/healthcareethicscourses.com\/\"\r\n      },\r\n      \"mainEntityOfPage\": \"https:\/\/healthcareethicscourses.com\/au\/knowledge-support\/osteopathy-board\/clinical-documentation-record-keeping-osteopaths\/\",\r\n      \"about\": [\r\n        {\r\n          \"@type\": \"Thing\",\r\n          \"name\": \"Osteopathy Board of Australia\"\r\n        },\r\n        {\r\n          \"@type\": \"Thing\",\r\n          \"name\": \"Osteopathy regulation in Australia\"\r\n        }\r\n      ]\r\n    },\r\n    {\r\n      \"@type\": \"BreadcrumbList\",\r\n      \"itemListElement\": [\r\n        {\r\n          \"@type\": \"ListItem\",\r\n          \"position\": 1,\r\n          \"name\": \"Home\",\r\n          \"item\": \"https:\/\/healthcareethicscourses.com\/au\/\"\r\n        },\r\n        {\r\n          \"@type\": \"ListItem\",\r\n          \"position\": 2,\r\n          \"name\": \"Knowledge & Support\",\r\n          \"item\": \"https:\/\/healthcareethicscourses.com\/au\/knowledge-support\/\"\r\n        },\r\n        {\r\n          \"@type\": \"ListItem\",\r\n          \"position\": 3,\r\n          \"name\": \"Osteopathy Board\",\r\n          \"item\": \"https:\/\/healthcareethicscourses.com\/au\/knowledge-support\/\"\r\n        },\r\n        {\r\n          \"@type\": \"ListItem\",\r\n          \"position\": 4,\r\n          \"name\": \"Clinical Documentation and Record Keeping for Osteopaths\"\r\n        }\r\n      ]\r\n    },\r\n    {\r\n      \"@type\": \"FAQPage\",\r\n      \"mainEntity\": [\r\n        {\r\n          \"@type\": \"Question\",\r\n          \"name\": \"What should an osteopathic record include?\",\r\n          \"acceptedAnswer\": {\r\n            \"@type\": \"Answer\",\r\n            \"text\": \"The presenting complaint and history, red-flag screening, examination findings including pertinent negatives, working diagnosis and reasoning, treatment and response, consent and any chaperone offer, and the review plan.\"\r\n          }\r\n        },\r\n        {\r\n          \"@type\": \"Question\",\r\n          \"name\": \"Why record consent and chaperone offers?\",\r\n          \"acceptedAnswer\": {\r\n            \"@type\": \"Answer\",\r\n            \"text\": \"For hands-on care near sensitive regions, documenting consent and any chaperone offer evidences that you practised safely and respected the patient's autonomy.\"\r\n          }\r\n        },\r\n        {\r\n          \"@type\": \"Question\",\r\n          \"name\": \"How long must osteopathy records be kept?\",\r\n          \"acceptedAnswer\": {\r\n            \"@type\": \"Answer\",\r\n            \"text\": \"Retention is set by state and territory law \\u2014 generally at least seven years from the last entry for adults, and for children until a specified age.\"\r\n          }\r\n        },\r\n        {\r\n          \"@type\": \"Question\",\r\n          \"name\": \"Can I amend a record after a complaint?\",\r\n          \"acceptedAnswer\": {\r\n            \"@type\": \"Answer\",\r\n            \"text\": \"Only transparently \\u2014 date the correction and never obscure the original. 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