Audit Compliance

Praxi helps you maintain AHPRA-compliant clinical documentation that will withstand professional audits.

AHPRA Documentation Standards

The Australian Health Practitioner Regulation Agency (AHPRA) requires:

1. Timely documentation - Notes written close to the session
2. Accurate records - Factual, objective content
3. Comprehensive - Includes all relevant clinical information
4. Legible - Clear and readable (automatic with digital)
5. Signed - Authenticated by the practitioner
6. Secure - Protected from unauthorised access

Note Status Flow

Clinical notes follow a strict status workflow:

Draft -> Final -> Signed (locked, immutable) -> Amended (if addendum added)

Once a note is signed, it is permanently locked and cannot be edited. Corrections must be made via an addendum (either supplementary or correction type), which transitions the note to Amended status. The snippet hierarchy follows the same governance model: System (managed by Praxi) -> Organisation -> Practitioner (Personal).

How Praxi Helps

Timeliness

• Dashboard shows unsigned notes
• Automated reminders at ~50% and ~75% of your profession's signing deadline
• Overdue notifications at 100% of the deadline (including supervisor notification)
• Signing timestamps recorded
• Overdue status captured in the audit trail with time past deadline
• Compliance reports available

Accuracy

• Session details auto-populated
• Date/time stamps automatic
• Version history tracked
• Corrections via addendum

Comprehensiveness

• Template-based structure
• Required sections enforced
• Risk assessment prompts
• Plan/follow-up included

Security

• Role-based access control -- Only authorised staff can view or edit clinical notes: the assigned practitioner, their supervisor, and organisation-wide oversight roles (practice owner, clinical governance) (see Roles and permissions)
• AES-256-GCM encryption -- All clinical data encrypted at rest
• Immutable audit logging -- All access recorded with 7-year retention
• Row-Level Security (RLS) -- Complete database-level tenant isolation between practices

Audit Trail

Every action is logged:

Event	Details Recorded
Note created	User, timestamp, client
Note edited	User, timestamp, changes, change reason
Note viewed	User, timestamp
Note signed	User, timestamp, credentials
Note signed late	User, timestamp, hours past deadline
Addendum added	User, timestamp, type (supplementary/correction)
AI attestation	User, timestamp, attestation text
Supervision submitted	User, timestamp, supervisor
Supervision approved	Supervisor, timestamp, feedback
Changes requested	Supervisor, timestamp, feedback
Note exported	User, timestamp, format
Note shared	User, timestamp, recipient
Note searched	User, timestamp, search query
Note duplicated	User, timestamp, original note
Draft restored	User, timestamp, recovery window
Note locked for editing	User, timestamp, lock expiry
Lock released/expired	User/system, timestamp
Compliance check run	User, timestamp, score, checks
Goal progress recorded	User, timestamp, goals updated
Action extracted	System, timestamp, action types
Action approved	User, timestamp, action type
Action dismissed	User, timestamp, reason

Access the audit log:

1. Open the note
2. Click Version History
3. See all events chronologically

Retention Requirements

Australian healthcare records must be retained per the Privacy Act and state health records legislation:

Client Type	Retention Period
Adults	7 years from last contact
Children	Until age 25, minimum 7 years

Praxi enforces these requirements automatically:

• 7-year immutable audit trail on all clinical records
• Prevents accidental deletion of records within retention periods
• Archives inactive records while maintaining accessibility
• Right to erasure requests (Privacy Act 1988) are handled via a managed workflow with exceptions tracked per entity with legal basis

Compliance Reports

Note Signing Report

Reports > Compliance > Note Signing

Shows:

• % of notes signed within the profession-tiered deadline
• Average time to signature
• List of overdue notes
• Trend over time

Access Report

Reports > Compliance > Record Access

Shows:

• Who accessed which records
• When access occurred
• What actions were taken
• Unusual access patterns

Risk Documentation Report

Reports > Compliance > Risk Assessment

Shows:

• % of notes with risk assessment
• Risk level distribution
• Notes missing risk assessment

Preparing for Audits

Regular Tasks

1. Daily - Sign notes within your profession's deadline
2. Weekly - Review unsigned notes report
3. Monthly - Check compliance dashboard
4. Quarterly - Review access logs
5. Annually - Full compliance audit

What Auditors Look For

1. Timely documentation
2. Consistent note structure
3. Risk assessment documentation
4. Appropriate access controls
5. Complete audit trails
6. Secure data handling

Providing Records

If you receive an audit request:

1. Contact your practice administrator
2. Export only requested records
3. Use secure transfer methods
4. Document what was provided
5. Keep copy of audit request

Best Practices

Documentation Quality

• Be factual and objective
• Use professional language
• Include relevant clinical detail
• Avoid unnecessary personal opinions
• Document risk at every session

Time Management

• Write notes immediately after sessions
• Block time for documentation
• Don't let notes pile up
• Set end-of-day signing routine

Privacy

• Only access records you need
• Don't share login credentials
• Log out when not in use
• Report suspicious access

Common Audit Issues

Issue	Prevention
Late signing	Enable reminders, sign daily
Missing risk assessment	Use templates with required fields
Incomplete notes	Review before signing
Inappropriate access	Role-based permissions
Lost records	Praxi handles retention

Insurance Implications

Proper documentation protects you:

• Professional indemnity claims
• Complaints to AHPRA
• Legal proceedings
• Medicare audits

Documentation Principle "If it isn't documented, it didn't happen." Good

documentation is your best protection in any professional challenge. :::

Next Steps

• Review note creation
• Set up reminders
• View compliance reports (Reports > Compliance)

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