Accurate and efficient clinical documentation is a professional obligation for all registered psychologists and allied health practitioners. This collection provides session note templates, case formulation frameworks, treatment plan structures, risk assessment documentation, and discharge summaries — all designed to meet the documentation standards expected by AHPRA, NDIS, Medicare, and private health insurers. Templates are adaptable to a range of practice settings including private practice, community health, and school psychology.
AHPRA requires psychologists to maintain adequate records of each client contact. Records should be completed promptly after each session and must be sufficient for another practitioner to understand the client's history, current presentation, and treatment plan.
Yes. The session note templates include provisions for documenting telehealth platform, consent, and technology suitability as required for telehealth Medicare items and good clinical practice.
