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Allied Health NDIS Audit Checklist: worksheet

Health records

Ahpra shared Code of conduct. Edition held: Shared Code of conduct, June 2022, in effect from 29 June 2022; checked current on 30 September 2026 (Ahpra code page read 30 September 2026: a review of the codes is under way, no revised version published).

Under review, not in force: A review of the shared code is under way; the June 2022 code stays in effect until a revised one is published.

Standards library: https://compliance.theartofservice.com/frameworks/ahpra-shared-code-of-conduct-2022. Page: https://allied-health-ndis-audit-checklist.theartofservice.com/rules/ahpra-code-of-conduct/8-3-health-records/

RefRequirement (our statement of the clause)Evidence an auditor or the regulator asks forCommon gap to checkHeld (yes, partly, no, not applicable)Where it is keptOwnerLast reviewedNext review
8.3Clear, accurate records are essential to continuing good care, and some Boards have specific records guidelines. Good practice means the practitioner: (a) keeps accurate, current, factual, objective, legible records of relevant clinical history, findings, investigations, information given, medication and other management, understandable to other practitioners; (b) keeps records secure from unauthorised access, safeguarding the privacy and integrity of electronic records in particular; (c) keeps records respectful and free of demeaning or derogatory remarks; (d) makes records sufficient for continuity of care; (e) writes records when events happen or as soon as practicable afterwards; (f) recognises and facilitates patients' right to access their records; and (g) promptly facilitates transfer or management, disposal included, of health information under privacy and health records law at a patient's request or on closure or relocation of a practice.
Source: https://www.ahpra.gov.au/Resources/Code-of-conduct/Shared-Code-of-conduct.aspx
Record-keeping audit against the Board's records guidance (history, findings, investigations, information given, medication, plan); Access controls and audit trail of the clinical records system; Records retention and disposal schedule under the state or territory health records law; Log of patient access and transfer requestsRecords written days after the consultation; Shared logins to the clinical system; Illegible or incomplete handwritten notes; No retention or disposal rule☐ yes
☐ partly
☐ no
☐ n/a

Completing this worksheet records what your practice holds and where. It does not make a practice compliant or ready for audit, and it is not legal advice.