In short
Good Medical Practice requires clear, accurate, contemporaneous and legible records that can be understood by others involved in a patient's care. Documentation concerns often accompany a clinical notification, because a gap in the record can look like a gap in care. The gravest error is not the original gap but altering, adding to or backdating a record after the event, which turns a manageable concern into a serious integrity matter. If a records notification is made, preserve everything exactly as it is, and respond honestly.
Why do medical records matter so much?
Because the record is how safe, continuous care is communicated, and a gap in the record is often read as a gap in care.
Good Medical Practice treats good record keeping as part of providing good care. Records carry information safely between clinicians, support continuity, and provide the account of what was assessed, decided and done. When a clinical concern is raised, the record is usually the first thing examined, which is why documentation so often features alongside clinical care in notifications about doctors. A thorough, contemporaneous note frequently answers a concern before it goes any further. For the overall process, see our guide to what happens after a notification to the Medical Board.
What does good record keeping require?
Records that are clear, accurate, contemporaneous, legible and able to be understood by others.
Do
- Record contemporaneously, or note the time of a delayed entry
- Be accurate, factual and objective
- Include your assessment, reasoning and plan
- Record consent, advice given and follow-up arranged
- Correct genuine errors openly, with a dated amendment
Never
- Alter, overwrite or delete an existing entry
- Add to or backdate a record after the event
- Record care or advice that was not provided
- Copy forward entries without checking them
- Write opinion or blame as if it were fact
Why must you never alter a record after the event?
Because altering, adding to or backdating a record turns a documentation gap into a far more serious integrity concern.
This is the single most important point. A brief or incomplete note is a documentation issue that can usually be addressed. Changing a record after you learn of a concern, or backdating an entry to fill a gap, is a matter of honesty, and it is treated far more seriously, potentially as professional misconduct. Electronic records carry audit trails, so changes are visible. If you realise something important is missing, the safe course is a clearly dated, honest addendum that states what happened and when you are recording it, never a quiet edit to the original entry.
What about access requests and retention?
Patients generally have a right to access their records, and records must be kept securely for the required period.
Good Medical Practice expects you to facilitate patients' access to information about their care and to keep records secure and confidential. Refusing a legitimate access request, failing to transfer records appropriately when a patient moves, or not retaining records for the required period can all become concerns. Handle access requests promptly and in line with privacy law, and make sure your practice has clear systems for secure storage, transfer and retention.
What outcomes can follow a records notification?
For genuine record-keeping gaps, often education; for altered or falsified records, far more serious outcomes.
A documentation gap, honestly acknowledged, is frequently resolved through education, a caution, or a condition to undertake training in record keeping, and sometimes with no further action. Where records have been altered or falsified, the matter becomes one of integrity and can lead to conditions, suspension or referral to a tribunal. Our guide to notification outcomes explains the full range. The gap between these two paths is exactly why honesty about the record is so important.
How can good records protect you?
A clear, contemporaneous record is often your strongest defence if a concern is ever raised.
It is easy to see documentation as a burden, but the record works in your favour far more often than against you. When a notification is made months or years later, memory fades, but a complete, contemporaneous record shows exactly what you assessed, decided, advised and arranged. It can demonstrate that your care met the standard even where the outcome was poor, and that consent was obtained and risks discussed. Doctors who document well are, in effect, protecting their own registration as well as their patients. Writing each note as the account you would want a Board to read is a habit that pays off precisely when it matters most.
What about copy-paste and templates in electronic records?
Templates and copy-forward save time, but cloned notes that do not reflect the actual encounter are a growing source of concern.
Electronic records make it easy to copy an entry forward or auto-populate a template, and used well these tools support consistency. The risk is a note that no longer reflects what actually happened, for example carrying over an examination that was not repeated, or a plan that no longer applies. If a copied note asserts findings or advice that were not part of that encounter, it is inaccurate, and in a notification an inaccurate note can be as damaging as a missing one. Review anything you copy forward, edit it to reflect the current consultation, and make sure each entry genuinely records that day's assessment. A tailored, accurate short note is always worth more than a long templated one that does not fit the patient in front of you.
How should you respond, and how can CPD help?
Preserve the record exactly as it is, respond honestly, and evidence a concrete change to how you document.
Do not touch the record. Contact your medical defence organisation, especially if integrity is in question, and prepare a reflective statement showing you understand why documentation is part of safe care. Evidence remediation such as documentation CPD and a changed routine, ideally with a short audit of your later records. Structured CPD on professional documentation, aligned with your CPD registration standard, gives dated evidence that you understand the standard and have embedded it. Browse the range of CPD for doctors.
Illustrative example
The concern: A doctor's notes did not record the risks discussed before a procedure, and consent was questioned after a complication.
Handling: The doctor did not alter the original note. They provided a dated addendum and their usual consent process, and explained honestly what was and was not recorded.
Reflection: They reflect on how a rushed note left the consent discussion undocumented, without minimising.
Remediation: They complete CPD on documentation, adopt a structured consent-recording template, and audit their later records to show the change held.
Matched to records concerns
Courses for a documentation notification
Structured CPD chosen for record-keeping concerns, to help you evidence remediation. Independent CPD you can use as evidence of remediation.
Professionalism in Documentation for Healthcare Professionals
- Directly targets the record-keeping concern
- Learn what accurate, timely records require
- Evidence a reliable documentation habit
Ensuring Clinical Competence and Patient Safety
- Links documentation to safe care
- Strengthen assessment and recording together
- Evidence competence for your response
Ensuring Confidentiality in Healthcare Practice
- Handle access, storage and disclosure
- Understand records and privacy law
- Evidence secure record handling
How to Deal With a Notification or Investigation
- Understand each stage of the Board's process
- Know what to do, and what to avoid, early
- Respond calmly and well prepared
Frequently asked questions
Can a doctor be reported for poor record keeping?
Yes. Good Medical Practice treats good records as part of good care. Incomplete, inaccurate or missing records are a common concern, often alongside a clinical notification. A genuine gap, honestly handled, is frequently resolved through education.
What does good medical documentation require?
Records that are clear, accurate, contemporaneous, legible and understandable by others involved in care. Include your assessment, reasoning, plan, consent, advice given and follow-up, and correct genuine errors openly with a dated amendment.
What happens if I altered a record?
Altering, adding to or backdating a record after the event is treated far more seriously than the original gap, potentially as professional misconduct. If you have already changed something, stop, contact your medical defence organisation, and be honest.
How do I correct a genuine error in the notes?
Never overwrite or delete the original. Make a clearly dated addendum that states what happened and when you are recording it, so the record stays honest and the audit trail remains intact. This is the safe way to fix a genuine omission.
Do patients have a right to access their records?
Generally yes. You should facilitate access to information about a patient's care, handle requests promptly and in line with privacy law, and transfer records appropriately when a patient moves. Refusing a legitimate request can become a concern.
Can good records protect me in a notification?
Yes. A complete, contemporaneous record often demonstrates that your care met the standard and that consent and risks were discussed, even where the outcome was poor. Good documentation is one of your strongest protections if a concern arises.
What outcomes are common for records concerns?
For genuine gaps, often education, a caution, or a condition to undertake training. Where records have been altered or falsified, the matter becomes one of integrity and can lead to conditions, suspension or referral to a tribunal.
Does CPD help with a documentation notification?
Yes. CPD on professional documentation, aligned with your CPD registration standard, gives dated evidence that you understand the standard and have changed your practice. It never guarantees an outcome, but it directly addresses the concern.
Dr Richard
Course Facilitator
A practising clinician with over 21 years of experience and postgraduate training in healthcare law and ethics, so every course reflects both clinical reality and Australian regulatory standards.
Written and reviewed by Dr Richard. Last reviewed . Read full profile
AHPRA Courses is an independent training provider. Our courses are structured CPD that practitioners can use as evidence of remediation. We are not affiliated with, endorsed by, or acting on behalf of Ahpra, the Medical Board of Australia, or any other regulator. Courses provide evidence of remediation and do not determine the outcome of any matter. This article is general information, not legal advice. If you have received a notification, seek advice from your medical defence organisation or a health law solicitor.