Clinical Notes & Assessments FAQ

Common questions about clinical documentation, notes, assessments, and compliance.

Clinical Notes

How do I create a clinical note?

1. From appointment: Click the appointment → Create Note
2. From client: Open client → Notes tab → New Note
3. From notes list: Notes → New Note → Select client

Notes are automatically linked to appointments when created from the calendar.

What note templates are available?

Standard templates include:

Template	Best For
SOAP	General sessions (Subjective, Objective, Assessment, Plan)
Progress Note	Ongoing therapy sessions
Initial Assessment	First session documentation
Mental Status Exam	Structured clinical assessment
Risk Assessment	Safety concerns and planning
Discharge Summary	End of treatment documentation

Custom templates can be created by practice owners in Settings → Note Templates.

Can I customise note templates?

Yes. Templates are available at three levels:

Level	Created By	Access
System	Praxi	All organisations
Organisation	Practice Owner	All staff in org
Personal	Individual	Creator only

To create a template:

1. Go to Settings → Note Templates
2. Click New Template
3. Design structure (sections, prompts, fields)
4. Set visibility level
5. Save

What are snippets?

Snippets are reusable text blocks you can insert into notes:

Examples:

• Standard intervention descriptions
• Frequently used phrases
• Homework instructions
• Resource recommendations

To use:

1. In the note editor, type / or click snippet icon
2. Search or browse snippets
3. Select to insert
4. Customise as needed

How do I sign a clinical note?

1. Open the note
2. Review content
3. Click Sign Note
4. Enter your password or MFA code
5. Note becomes locked and immutable

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Signing Deadline

Your practice requires clinical notes to be signed within the configured deadline. Unsigned notes older than the deadline trigger reminders in Praxi.

Can I edit a signed note?

No. Signed notes are locked and immutable for compliance. This ensures:

• Audit trail integrity
• Legal defensibility
• AHPRA compliance

To correct a signed note:

1. Create an addendum (addition)
2. Reference the original note
3. Document the correction
4. Sign the addendum

Who can see my clinical notes?

Access depends on role and settings:

Role	Default Access
Note Author	Full access
Supervisor	Supervisee notes (if assigned)
Practice Owner	All notes across the organisation
Practice Manager	No clinical note access
Other Practitioners	Only if explicitly shared
Receptionist	No clinical note access
Accountant	No clinical note access

Can I share notes with another practitioner?

Yes. To share a note:

1. Open the note
2. Click Share or sharing icon
3. Select practitioner(s)
4. Choose access level (view or edit)
5. Save

Shared access is logged for audit purposes.

How long are notes retained?

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Privacy Act 1988 Retention Requirements

Clinical records must be retained for minimum periods as set out below. Praxi enforces these retention rules automatically. Records cannot be deleted before the minimum retention period expires.

Record Type	Retention Period
Adult clients	7 years minimum from last service
Children (no child-sexual-abuse content)	Until the client turns 25, or 7 years from last service — whichever is later
Records relating to child sexual abuse (occurred or alleged)	At least 45 years (Royal Commission into Institutional Responses to Child Sexual Abuse, Final Report Volume 8) — use legal hold so purge/erasure cannot shorten this
Deceased clients	7 years from death (if known)

Praxi enforces general floors and supports legal hold for longer statutory or Royal Commission holds. Notes under minimum retention or legal hold cannot be permanently deleted.

AI Features

How does AI note assistance work?

When enabled, AI assists with:

1. Transcription: Voice recording → text
2. Suggestions: Based on session content
3. Structure: Organises content into sections
4. Spelling/grammar: Corrections

AI suggestions appear as highlights. Accept, modify, or reject each suggestion.

Is AI transcription accurate?

AI transcription typically achieves:

Audio Quality	Accuracy
Clear, quiet room	95%+
Some background noise	85-95%
Significant noise	70-85%

Tips for best results:

• Use a quality microphone
• Minimise background noise
• Speak clearly
• Review and correct transcriptions

Is client data used to train AI?

No. Praxi AI features:

• Use Australian-hosted Claude AI
• Do not train on your data
• Process in real-time without storage
• Comply with Privacy Act requirements

See our privacy policy for full details.

How do I enable/disable AI features?

1. Go to Settings → AI Settings
2. Toggle individual features:
   • Voice transcription
   • Note suggestions
3. Changes apply immediately

AI features can be enabled organisation-wide or per-practitioner.

Does AI flag risk indicators?

No. Praxi's AI does not analyse notes or sessions for risk and does not rate risk. You assess risk and record it in the client's risk register and your note. When a note is drafted from a session, risk content appears only as it was discussed, and the risk section reads "not discussed" if it was not.

Assessments

What assessments are available?

Standard validated assessments:

Assessment	Measures	Items
DASS-21	Depression, Anxiety, Stress	21
PHQ-9	Depression severity	9
GAD-7	Anxiety severity	7
K10	Psychological distress	10
PCL-5	PTSD symptoms	20

Additional assessments available on Pro plans and above.

How do I send an assessment to a client?

1. Go to client profile → Assessments tab
2. Click Send Assessment
3. Select assessment type
4. Choose delivery method (email or portal)
5. Set due date (optional)
6. Send

Client completes via secure link. Results appear automatically.

Can clients complete assessments before their appointment?

Yes. You can:

1. Schedule in advance: Set send date when booking
2. Automate: Configure workflow to send before first session
3. Portal access: Client completes anytime via portal

Results are available to view before the appointment.

How do I interpret assessment results?

Assessment scores include:

• Numerical score: Raw total
• Severity level: Clinical interpretation (e.g., mild, moderate, severe)
• Comparison: To previous assessments (if available)
• Subscales: Where applicable (e.g., DASS-21 subscales)

Clinical interpretation guides are available in each assessment's results view.

Can I track assessment progress over time?

Yes. For each client:

1. Go to Assessments tab
2. View Progress or graph icon
3. See scores over time
4. Compare severity levels
5. Export for reports or letters

Useful for demonstrating treatment effectiveness.

Consent & Compliance

How do I record client consent?

1. Open client profile → Consent tab
2. Add consent type:
   • Treatment consent
   • Information sharing
   • Recording consent
   • Medicare/funding consent
3. Record method (verbal, written, electronic)
4. Add details and date
5. Save

How does consent work for minors?

Consent rules follow the Family Law Act 1975:

Age	Who Consents
0-13	Guardian only
14-17	Client + Guardian (both required)
18+	Client only

Praxi automatically enforces these rules based on client date of birth.

Can I record sessions?

Yes, with proper consent. Recording workflow:

1. Obtain consent in writing (recorded in Praxi)
2. Enable recording in appointment settings
3. Start recording during session
4. Auto-transcription (if enabled)
5. Store securely with client record

What are mandatory reporting obligations?

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Mandatory Reporting

Mandatory reporting obligations are governed by your registration body and state/territory child protection legislation. Praxi provides prompts and documentation tools but does not automate mandatory reports — clinical judgement and professional obligations remain with the practitioner.

For Australian practitioners:

Situation	Action Required
Child abuse/neglect	Report to child protection services
Risk of harm to self	Document, safety plan, may notify
Risk of harm to others	Document, may warn, may notify
Impaired practitioner	Report to AHPRA

Praxi provides reporting prompts but does not automate mandatory reports.

How do I document a mandatory report?

1. Create clinical note documenting concerns
2. Record decision-making process
3. Document report made (date, agency, reference)
4. Follow up actions
5. Sign note promptly

Keep all documentation secure within the client record.

Supervision

How does supervision work in Praxi?

For supervised practitioners (interns, registrars):

1. Supervisor assigned by practice owner
2. Notes flagged for review before signing
3. Supervisor reviews and approves/returns
4. Co-signature recorded
5. Session logged for hours tracking

Can supervisors access all my notes?

Only if assigned as your supervisor. Access includes:

• Notes awaiting review
• Previously reviewed notes
• Session counts and hours

Supervisors cannot access notes for clients they don't supervise.

How do I track supervision hours?

1. Go to Supervision in the sidebar (or supervisor dashboard)
2. View logged hours by:
   • Direct client contact
   • Supervision received
   • Indirect hours
3. Export for registration requirements

Hours auto-calculate from signed notes and supervision sessions.

Letters & Reports

How do I create a GP letter?

1. Open client → Documents or Letters
2. Click New Letter → GP Letter
3. Select template (referral acknowledgement, progress, discharge)
4. Auto-populates client, GP, and session details
5. Edit and customise
6. Generate PDF
7. Send or download

Can I generate reports from note content?

Yes. Available reports:

Report	Content
Treatment Summary	Session dates, interventions, progress
Assessment Report	All assessments with scores and interpretation
Discharge Summary	Treatment overview, outcomes, recommendations

Auto-generated from note and assessment data.

How do I share clinical documents externally?

Options:

Method	Use Case
Secure email	To verified healthcare providers
Portal	To client for their records
Download PDF	For physical delivery
Fax	To organisations requiring fax

All sharing is logged for audit.

Troubleshooting

Note won't save?

Check:

1. ✅ Required fields completed
2. ✅ Internet connection stable
3. ✅ Session hasn't timed out (re-login)
4. ✅ Not a signed note (create addendum instead)

Work is auto-saved every 30 seconds. Check Drafts if needed.

Can't sign note - getting error?

Possible causes:

Error	Solution
Password incorrect	Re-enter or reset password
MFA required	Enter authenticator code
Note incomplete	Fill required sections
Supervision required	Wait for supervisor approval

Assessment link not working for client?

Check:

1. ✅ Link hasn't expired (default 7 days)
2. ✅ Correct email address
3. ✅ Check client's spam folder
4. ✅ Resend if needed

Voice transcription not working?

Check:

1. ✅ Browser has microphone permission
2. ✅ Microphone selected correctly
3. ✅ AI features enabled in settings
4. ✅ Internet connection stable

Test microphone in browser settings first.

Related

• Clinical Notes Overview
• Creating Notes
• Signing Notes
• Assessments Overview
• AI Agents

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