Patient health records

The biggest change to the guidelines regards the language that patient health records are made in, which applies only to practitioners with English language conditions on their registration. Outside of this, the updated guidelines now include information on virtual care, the shared Code of conduct and artificial intelligence. The Board also made minor updates to language, wording and formatting.

Yes. The Board invited responses to a public consultation that ran from April to June 2024. The consultation papers, consultation report and feedback received can be found on the Past Consultations page.

Provided that all requirements set out in the updated guidelines and relevant state and territory laws are complied with, it is up to practitioners to decide how they make their patient health records. Practitioners who opt to make their records electronically must ensure that there is a process for secure transmission of records and a backup must be maintained.

Chinese medicine practitioners should be aware that a request for access to records can come at any time, including from other health practitioners in an emergency, and it is the practitioner’s responsibility to respond to these requests without delay.

When formally requested by the patient, the transfer of health information is to be done promptly and securely, in accordance with the relevant state, territory and Australian laws relating to privacy and patient health records information. Patients should be advised of the location of patient health records on request. Practitioners should keep a record of any such requests.

Patient health records are legal documents. An adequate record of every patient consultation is an essential part of competent Chinese medicine practice for the following reasons:

1. Good patient health records facilitate high-quality and comprehensive care by making detailed and relevant information (current and historical) readily available to any treating practitioners.
2. Patient health records can provide a repository of valuable information for teaching, education and research.
3. Patient health records should be the basis for quality management and improvement activities undertaken regularly by Chinese medicine practitioners.
4. Patient health records form the basis for retrieval of treatment details to assist in disputes or in giving evidence and may, in themselves, be used as evidence in courts and tribunals.

The guidelines refer to two types of records: accounting records and clinical records.

Accounting records

Taxation law requires small business accounting records to be held for at least 5 years after they were prepared, and for longer if they are to be used in a later tax return.

See the Australian Taxation Office website for more information on record keeping for small business.

Clinical records

All states have requirements for health record retention in the public sector, but only Victoria, NSW and ACT have laws that apply to private sector health records. In these states private sector health records must be kept for seven years after the last treatment was provided for an adult patient. Where the patient was aged less than 18 years, records must be kept until the patient turns 25 years old.

In states without specific record retention policies registrants are reminded that records are created and maintained to serve the best interests of patients and to contribute to the safety and continuity of their Chinese medicine care. Patient records are also necessary to respond to patient complaints. For these reasons records should not only be retained until they are no longer required to manage the patients care, but also until after the statute of limitations on personal injuries has expired in that state.

It is the registrant’s responsibility to be familiar with and comply with their relevant state laws regarding patient health record retention.

See the Office of the Australian Information Commissioner website for more information on state and territory legislation.

Generally, the health service provider who creates a patient health record owns that record. Self-employed practitioners, running their own practice, are considered to own their patient health records. In a group practice however, the owner of the records will depend on the contractual relationship between the practice owner and the practitioner. To avoid disputes, practitioners should clarify the matter of ownership of patient records before commencing practice in a group practice.

Commonwealth privacy legislation still gives patients’ rights regarding access to a patient’s records irrespective of who owns the records.

Read more about My Health Record - the national digital health record system.

The main change that practitioners with English language conditions on their registration must be aware of is that, once effective on 1 January 2026, the updated guidelines will require more elements of the patient health record to be recorded in English than the previous version of the guidelines. In addition to patient identifiers and emergency contact details, practitioners with English language conditions will have to make the following parts of their records in English:

1. Chinese medicine diagnosis and, where applicable, main complaint, relevant clinical impression, reasoning or interpretation
2. If known, it is preferred that a Western medicine diagnosis be recorded in English, but this is not mandatory
3. Prescription of acupuncture and / or prescription of Chinese herbal medicines
4. Any use of Chinese herbal medicine products in treatment provided
5. Any unusual reactions, side effects that may follow treatment, or possible adverse events.

Full details and further guidance on these requirements can be found in the updated guidelines.

Public protection is the paramount objective in the National Registration and Accreditation Scheme (NRAS). The Board is implementing these changes to the updated guidelines to improve regulatory alignment, improve continuity of care for patients and reduce the risk of harm to the public. A full explanation of the Board’s rationale can be found in the Consultation report on the public consultation on the proposed revised guidelines on patient health records on the Board's Past consultation page.

The updated guidelines come into effect on 1 January 2026. From that date, any new health record practitioners make must adhere to the updated guidelines. Practitioners are not required to translate records made in a language prior to 1 January 2026, unless they receive a valid request to do so.

A request for access to patient health records can come at any time, including from other health practitioners in an emergency, and it is a Chinese medicine practitioner’s responsibility to respond to these requests without delay. The translation of records is the responsibility of the Chinese medicine practitioner, and the Chinese medicine practitioner is to be fully satisfied that the translation is comprehensive, accurately reflects the content of the original patient health record and follows this guideline.

Patients have a right to access their health information or record, and in some jurisdictions this right is enforceable under legislation. When formally requested by the patient, the transfer of health information or record is to be done promptly and securely, in accordance with the relevant state, territory and Australian laws relating to privacy and patient health records information. Patients should be advised of the location of patient health records on request. Practitioners should keep a record of any such requests.

Referrals to other health services should be made in English, with copies kept in the patient health record.

The guidelines will be used as evidence of what constitutes appropriate professional conduct and practice for Chinese medicine during an investigation or other proceedings about a registered Chinese medicine practitioner. Practitioners who are found not to comply may lead to findings of inappropriate professional conduct. Practitioners should be aware that the Board is able to conduct an audit at any time.

It is the responsibility of practitioners that they make accurate and comprehensive patient health records. This includes parts of the record that are recorded in English. The Board does not have a resource for translation of Chinese medicine terminology, however the Nomenclature compendium for Chinese herbal medicines gives the names of herbal medicines in various ways, including pinyin, simplified Chinese characters and traditional Chinese characters.

If a practitioner is not satisfied that they can translate a Chinese medicine term into English accurately, they may wish to contact their professional association.

The Board cannot endorse any translation software or online tools, however it recognises that some practitioners may use such technology. In such cases, practitioners should be aware that it is their responsibility to ensure that the translation is comprehensive and accurate. Any use of AI should be undertaken in accordance with the Ahpra guidance Meeting your professional obligations when using Artificial Intelligence in healthcare.