Clinical Notes Overview

Praxi's clinical notes system is designed to meet Australian healthcare documentation standards while saving you time.

Key Features

• AHPRA-compliant documentation
• Configurable signing deadlines -- default is 24 hours for all professions; your practice can configure this to any value in the supported range
• Immutable audit trail once signed
• Snippet hierarchy -- System (managed by Praxi), Organisation, and Practitioner (Personal) levels
• Two-mode editor -- Template Mode for configuring note structure with AI toggles per section, Note Mode for rich text editing with resolved fields
• AI-powered note generation with per-section streaming, review controls (accept/refine/delete), linked evidence citations, and post-processing
• Library-based AI -- AI selects from curated clinical snippets rather than generating freeform text, making output predictable and swappable
• Multi-format export -- raw text, formatted HTML, markdown, and PDF
• Voice transcription for dictation-to-note workflows
• Note locking -- prevents concurrent editing with 15-minute auto-expiry
• Natural language search -- find notes by meaning, not just keywords
• AI action extraction -- automatically identifies tasks, homework, assessments, referrals, GP letter triggers, and MBS suggestions from signed notes
• Smart Sections -- regenerate individual note sections using per-section AI prompts
• Clinical letter generation -- AI-drafted referral letters, discharge summaries, NDIS progress reports, school/workplace letters, MHTP reviews, and court report frameworks
• Pre-session briefs -- AI-generated session preparation summaries delivered before appointments
• Session memory and theme tracking -- longitudinal client context with theme lifecycle (emerging, active, resolving, resolved)
• Note duplication -- duplicate an existing note as a new draft
• Draft recovery -- restore deleted draft notes within a 30-day window
• AHPRA compliance checks -- real-time documentation completeness checks against AHPRA Standard 4.4.4

Note Types

Praxi supports a comprehensive range of clinical note types:

Note Type	Description
Progress Note	Standard session documentation
Initial Assessment	First consultation documentation
Discharge Summary	End of treatment documentation
Treatment Plan	Formal treatment planning
Case Consultation	Peer consultation records
Incident Report	Clinical or safety incidents
Group Note	Group therapy session documentation
Telephone Contact	Phone consultations and check-ins
Supervision Note	Supervision session records
Psychological Assessment	Formal psychological assessment
Risk Assessment	Dedicated risk evaluation documentation
Medication Review	Medication-related session records
Transfer Note	Client transfer or handover documentation
Case Conference	Multi-party case conference records
Forensic Assessment	Forensic and medico-legal assessments
Court Report	Court-ordered assessment documentation

Note Status Workflow

Status	Description	Can Edit?
Draft	Work in progress	Yes
Awaiting Signature	Complete, ready for signing	Yes
Overdue	Draft past the signing deadline -- sign it now	Yes
Signed	Signed by author -- locked and immutable	No
Amended	Signed note that has had an addendum added	No

Once a note is signed it is permanently locked and cannot be edited. Corrections must be made via an addendum, which transitions the note to Amended status.

Signing Deadline

Signing Deadline

Clinical notes should be signed promptly after the session. The default signing deadline is 24 hours. Your practice administrator can configure this deadline in the practice settings. :::

Praxi helps you meet signing deadlines:

• Shows unsigned notes on your dashboard
• Sends reminders at approximately 50% and 75% of your organisation's signing deadline
• Sends overdue notifications (and notifies your supervisor, if applicable) once the deadline has passed
• Tracks signing times for compliance reporting

Note Structure

A typical note includes:

1. Header

   • Client name
   • Session date and time
   • Service type
   • Practitioner name

2. Body

   • Session content (customisable sections)
   • Clinical observations
   • Interventions used
   • Client response

3. Risk Assessment

   • Current risk level
   • Risk factors identified
   • Safety plan if applicable

4. Plan

   • Homework/tasks for client
   • Next session date
   • Follow-up actions

5. Footer

   • Signature
   • Date/time signed
   • Credentials

Privacy and Security

Notes are protected by:

• Role-based access - Only authorised staff can view or edit notes; practitioners access their own clients' notes, and clinical supervisors and practice owners have practice-wide oversight
• Audit logging - All access is recorded with 7-year retention under the Privacy Act 1988
• Encryption - AES-256-GCM encryption at rest, TLS in transit
• Tenant isolation - Complete database-level separation between practices via Row-Level Security

Quick Actions

Shortcut	Action
Cmd+S	Save note
Cmd+Enter	Save and close
Cmd+Shift+S	Sign note
Cmd+/	Insert snippet

Next Steps

• Creating notes
• Note templates
• Using snippets
• Signing notes
• Couples and group notes
• Audit compliance
• Exercise prescriptions
• Supplement protocols
• Functional pathology
• Herbal dispensary

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