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AHPRA Compliance for AI Documentation: Complete Guide 2025 | Avand Health

AHPRA Compliance for AI Documentation: Complete Guide 2025 | Avand Health

Navigate AHPRA standards for AI-powered clinical documentation with confidence

AI Mental Health Research TeamAI Mental Health Research Team
8 minCompliance & Legal

Australian mental health practitioners using AI documentation tools must navigate AHPRA compliance requirements while leveraging technology to save 10-25 minutes per therapy session. In August 2024, AHPRA released comprehensive guidance titled “Meeting your professional obligations when using Artificial Intelligence in healthcare” that establishes clear expectations for all registered health practitioners ¹.

This guide breaks down AHPRA's five core principles and provides a practical compliance framework for psychologists, counsellors, and therapists implementing AI clinical documentation solutions. Whether you're evaluating AI transcription tools or already using them, understanding these requirements ensures you can benefit from efficiency gains while maintaining full regulatory compliance with HIPAA, AHPRA, and the Australian Privacy Act.

Key Points

  • • AHPRA published AI guidance in August 2024 establishing five core compliance principles
  • • Practitioners remain fully responsible for all AI-assisted documentation
  • • Proper implementation enables 2-3 additional client sessions daily
  • • New Psychology competencies taking effect December 2025 include digital health requirements
  • • Most AI scribing tools are NOT TGA-regulated—requiring extra due diligence

Note: This guide provides general compliance information. Always consult your professional indemnity insurer and AHPRA directly for specific guidance on your situation.

2.The Five AHPRA Principles for AI Use

AHPRA's guidance outlines five key principles that practitioners must follow when using AI in their practice ¹. Understanding these principles is essential for compliant AI documentation implementation.

1. Accountability

You remain fully responsible for all clinical documentation, even when using AI assistance. TGA approval of an AI tool does not change your responsibility to apply human oversight and judgment.

Practical implication: Review and verify every AI-generated note before finalising. Maintain audit trails showing your review and approval.

2. Understanding

Practitioners must understand enough about their AI tools to use them safely. At minimum, review product information about how the AI is trained, tested, intended use, limitations, and contexts where it should not be used.

Practical implication: Request documentation from AI vendors. Understand if the tool was trained on Australian clinical contexts and mental health terminology.

3. Transparency

Inform patients about AI tool usage in their care. The level of detail depends on the application—recording consultations requires more detailed disclosure than using AI for administrative tasks.

Practical implication: Update your privacy policy and include AI usage in consent forms. Consider any concerns patients raise about AI.

4. Informed Consent

Involve patients in decisions about using AI tools that process their personal data. Explain how information is collected, used, and whether it contributes to AI model training.

Practical implication: Document consent in health records. Specify how data will be used and stored. Learn more about our data security practices.

5. Ethical and Legal Considerations

Ensure compliance with privacy legislation ², maintain professional indemnity insurance coverage, address potential algorithmic bias, and follow TGA requirements where applicable.

Practical implication: Verify Australian data sovereignty. Check if your AI vendor addresses bias in diverse populations. Update your insurance provider about AI usage.

3.TGA Regulatory Context: What's Regulated and What's Not

Understanding TGA regulations helps practitioners navigate their compliance obligations . Not all AI tools in healthcare are TGA-regulated.

TGA-Regulated AI

Software with a therapeutic use that meets the definition of a medical device:

  • • Diagnostic imaging AI
  • • Clinical decision support systems
  • • Treatment recommendation algorithms
  • • AI that directly affects treatment decisions

NOT TGA-Regulated

General purpose AI tools without therapeutic use:

  • • AI transcription/scribing tools
  • • Documentation assistants
  • • Administrative automation
  • • Practice management AI features

Important: Most AI documentation tools like scribes and note generators are NOT TGA-regulated. This means practitioners bear additional responsibility for evaluating these tools' safety, accuracy, and fitness for purpose. See our features page to understand how Avand Health meets these requirements.

4.Implementation Framework

Successfully implementing AI documentation requires a systematic approach. This three-phase process ensures compliance while maximising efficiency gains of 10-25 minutes saved per session.

Phase 1: Preparation (Weeks 1-2)

  • • Evaluate AI tool against AHPRA's five principles
  • • Verify Australian data sovereignty and security compliance
  • • Update professional indemnity insurance
  • • Revise consent forms and privacy policy to include AI usage
  • • Develop internal “Use of AI” policy

Phase 2: Pilot Testing (Weeks 3-4)

  • • Train all staff on AI system operation
  • • Test with volunteer clients who consent to pilot
  • • Establish documentation review protocols
  • • Document time savings and quality metrics
  • • Address any accuracy or bias concerns identified

Phase 3: Full Implementation (Weeks 5-6)

  • • Roll out to all practitioners
  • • Monitor compliance metrics continuously
  • • Collect client feedback on AI disclosure
  • • Optimise workflows for maximum efficiency
  • • Schedule quarterly compliance reviews

Total implementation time: 20-30 hours over 6 weeks. ROI typically achieved within 2-3 months through time savings enabling 2-3 additional client sessions daily. View our pricing options to calculate your potential savings.

5.AHPRA AI Compliance Checklist

Use this checklist to verify your AI documentation implementation meets all AHPRA requirements:

Pre-Implementation

  • AI tool documentation reviewed (training data, intended use, limitations)
  • Australian data sovereignty confirmed
  • Professional indemnity insurer notified
  • Privacy policy updated with AI disclosure
  • Consent forms revised to include AI usage
  • Internal “Use of AI” policy developed

Ongoing Compliance

  • All AI-generated notes reviewed within 24 hours
  • Audit trails maintained for all documentation
  • Patient consent documented in health records
  • Regular accuracy and bias monitoring
  • Quarterly compliance reviews scheduled

December 2025 Update: New Psychology Board competencies taking effect December 1, 2025 include digital health requirements. Ensure your AI implementation aligns with these updated professional competencies ³.

6.Common Questions

Q: Do I need to inform AHPRA about using AI documentation?

Currently, AHPRA does not require specific notification when using AI documentation tools. However, you must ensure your practice meets all existing documentation standards, update your professional indemnity insurance provider, and include AI usage in your patient consent forms and privacy policy.

Q: How quickly should I review AI-generated notes?

Best practice suggests reviewing AI-generated notes within 24 hours while the session is fresh. Review typically takes 3-5 minutes, maintaining the overall time saving of 10-25 minutes per session. You must verify accuracy and relevance before finalising any clinical documentation.

Q: Can AI notes be used as legal evidence?

Yes, AI-assisted notes can be used as legal evidence when properly reviewed and approved by the practitioner. Maintain comprehensive audit trails showing practitioner review timestamps and preserve both original AI-generated and edited versions. The practitioner remains fully accountable for the final documentation.

Q: Is AI transcription software regulated by the TGA?

Generally, no. The TGA regulates therapeutic goods including software with a therapeutic use. However, generative AI tools like AI scribing are usually intended for general purposes and do not have a therapeutic use, so they are not TGA-regulated. This means practitioners must exercise additional due diligence in evaluating these tools.

Q: What about My Health Record integration?

AI documentation systems can integrate with My Health Record using FHIR R4 standards and the Healthcare Identifiers Service. Upload clinical summaries rather than detailed session notes. Ensure your AI tool complies with My Health Record security requirements.

7.Next Steps

AHPRA compliance and AI documentation work together to enhance your practice. With proper implementation following the five principles, you can save 10-25 minutes per therapy session while maintaining the highest professional standards.

Action Items

  1. Review AHPRA's official AI guidance and case studies
  2. Assess your practice's readiness using the checklist above
  3. Update consent forms and privacy policies
  4. Choose an AHPRA-compliant AI documentation solution
  5. Plan your implementation timeline using the framework provided
  6. Calculate your potential ROI with our pricing calculator

Disclaimer: This guide provides general information about AHPRA compliance for AI documentation. It is not legal advice. Consult your professional indemnity insurer, AHPRA, and legal advisors for specific guidance. Revenue projections are estimates and individual results may vary.

[1]
AHPRA AI Guidance - AHPRA (2024). Meeting your professional obligations when using Artificial Intelligence in healthcare. Available at: https://www.ahpra.gov.au/Resources/Artificial-Intelligence-in-healthcare.aspx
[2]
Australian Privacy Principles - Office of the Australian Information Commissioner (2024). Privacy and AI Guidance. Available at: https://www.oaic.gov.au/privacy/australian-privacy-principles
[3]
Psychology Board Guidelines - Psychology Board of Australia (2024). Clinical Record Keeping Guidelines. Available at: https://www.psychologyboard.gov.au/Standards-and-Guidelines/Code-of-conduct.aspx
[4]
My Health Record - Australian Digital Health Agency (2024). Healthcare Provider Resources. Available at: https://www.digitalhealth.gov.au/healthcare-providers/my-health-record
[5]
TGA Medical Device Guidance - Therapeutic Goods Administration (2024). Software and AI Medical Devices. Available at: https://www.tga.gov.au/how-we-regulate/manufacturing/manufacture-medical-device

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