AHPRA Record Keeping for Allied Health: What Software Can Support and What You Still Decide
By The Kitt Team
Two mistakes show up regularly in how clinicians think about practice software. The first is assuming the tool makes the record compliant by existing. The second is assuming that any AI in the loop is a registration risk. Both place the obligation in the wrong place: with the software, rather than with the clinician. For full rules and retention detail, see clinical documentation obligations; this post deals with the split between you and your software.
What AHPRA record keeping actually asks of you
AHPRA record keeping refers to the standard in the shared code of conduct for registered health practitioners including physiotherapists, podiatrists, chiropractors and occupational therapists. That standard asks for accurate, up to date, factual, objective and legible records. They must cover history, findings, investigations, information given to the client and management plans, be understandable by another practitioner, held securely and made at the time of the events or as soon as practicable afterwards.
AHPRA registers practitioners, not software, so the standard attaches to you. Accredited exercise physiologists are not registered with AHPRA; they are accredited through Exercise and Sports Science Australia, whose professional standards ask for the same kind of accurate, clear and up to date record. The Privacy Act 1988 and the Australian Privacy Principles apply to every organisation providing a health service, regardless of practice size.
The Physiotherapy Board of Australia reported 47,761 registered physiotherapists in its 2024/25 annual summary, up 6.4 per cent on the year before.
The obligation does not move when the software arrives
AHPRA and the National Boards have published guidance on using AI in healthcare. The practitioner remains responsible for their practice when using AI. The guidance asks clinicians to understand the tool well enough to use it safely, including how it handles client data; be transparent with clients; seek informed consent before recording a consultation or entering the client’s information into an AI tool and note the response in the record; and check AI-drafted records for accuracy and relevance.
None of that is new. A note drafted by software and approved by you is your note.
The question is not whether the tool is compliant, but which parts of your obligation it makes easier to meet and which parts stay with you.
The Australian Physiotherapy Association’s 2025 Workforce Census found that 34 per cent of practice owners named regulatory and funding complexity a key business threat, up from 22 per cent.
What software can support, and what you still decide
Every record-keeping obligation has a mechanical side and a judgement side. Software carries the mechanical side; you own the judgement.
| The obligation | What software can support | What you still decide |
|---|---|---|
| Made at the time | Drafting from the consultation itself, so the record exists the same day instead of later | Reviewing and approving it while the session is fresh, deciding when it is final |
| Accurate and factual | Capturing what was said and done | Checking against what actually happened, correcting anything wrong, missing or not said |
| Covers findings and management | A consistent structure that prompts each part | What is clinically relevant, the reasoning linking findings to plan |
| Understandable by another practitioner | Consistent headings and plain complete sentences instead of private shorthand | Whether a colleague reading it cold could pick up the client’s care |
| Consent recorded | A place in the record to note it | Telling the client about the tool, asking for consent, recording their answer |
| Corrections visible | Tracking edits to a finished record, so changes read as changes | Whether a correction is needed, making it openly not quietly |
| Secure and retained | Encryption, controlled access, retrievable records | Who in your practice can access, choosing a tool you understand, knowing retention rules in your state or territory |
A record made at the time beats one written on Sunday night. Every row on the right is judgement, and judgement is what registration is about. Knowing the checks a reviewer runs on a note is part of understanding what you are approving.
A 2016 study of United States physicians (Sinsky and colleagues, Annals of Internal Medicine) found they spend about two hours on electronic health record and desk work for every one hour of direct clinical care, with a further one to two hours of after-hours clerical work. This is United States physician data, not Australian allied health evidence.
How to judge a tool against the split
Ask whether it drafts the record from the session itself, so the note exists before the next client walks in.
Ask whether you review and approve every record before it is final. If a tool finalises or sends on its own, that decision belongs in your column.
Ask whether edits to a finished record are tracked, how data is stored and who can access it. Expect a straight answer.
Ask where the record ends up. If you run a practice management system, check whether the note can land there so you have one record, not two.
A tool that does the left column well gives you time for the right. A tool that tries to do the right column for you is the one to be wary of. To test a tool’s note accuracy before committing, start there.
Where kitt fits
kitt is the one place that brings both sides of a client’s care together. The plan goes out through kitt Companion; adherence and pain come back between visits, so the next record starts from what actually happened.
kitt drafts the note, letter and treatment plan from the consultation, structured and editable. Client Contextual Memory surfaces prior findings, progression and goals before each session, keeping the record as one continuous narrative. Edits are tracked with an audit trail. Client records are encrypted. The completed note can be pushed to Cliniko or Nookal; the integration is optional.
kitt drafts, you decide. Every note, letter and plan returns for your review and approval; clinical reasoning and consent stay with you.
kitt documentation supports clinicians’ AHPRA record-keeping obligations.
The Professional plan is A$69 per clinician per month with Companion included. Try kitt free for a month, no card required.
Frequently asked questions
What are AHPRA’s record keeping requirements for allied health?
Registered allied health practitioners work under the shared code of conduct, which asks for accurate, up to date, factual and legible records. Records must cover history, findings, information given to the client and management, be understandable by another practitioner, held securely and made at the time of the events or as soon as practicable afterwards. Accredited exercise physiologists are not registered with AHPRA; they are accredited through Exercise and Sports Science Australia, whose professional standards ask for the same kind of accurate, clear and up to date record.
Does using clinical software make my records AHPRA compliant?
No. AHPRA registers practitioners, not software, so the obligation stays with you. Good software supports the mechanical parts; accuracy, reasoning, consent and sign-off stay with the clinician.
Do I need my client’s consent to use an AI scribe?
AHPRA’s guidance on AI says practitioners should tell clients about the tool, seek informed consent before recording or entering the client’s information into an AI tool, and note the response in the record.
How long do I need to keep clinical records?
Retention periods are set by state and territory legislation and vary. The period generally runs from the date of the last entry, and records for a client who was a child are kept longer. Check your state’s requirements rather than relying on a single national figure.
The takeaway
- AHPRA record keeping attaches to the registered clinician, not software.
- Every obligation splits into a mechanical part a tool can support and a judgement part that stays with you.
- AHPRA’s guidance applies the existing standard to new tools. It does not create a new one.
- Judge a tool by how well it carries the left column, and whether it leaves the right column with you.
The split does not change because the tool is good. It is how the standard works.