Treatment Notes

At NMK, completion of Clinical Treatment Notes — including a Treatment Plan — is a legal and professional requirement for every consultation.

SOAP notes are a critical component of client care, continuity between therapists, and professional accountability. As such, incomplete or partially completed notes that do not include a Treatment Plan are not accepted at NMK.

Contracted therapists are unable to invoice for treatments where SOAP notes have not been completed in accordance with the requirements outlined below.

Documentation Requirements

As outlined in each Team Member’s Contractor Agreement (Clause 15) or Employment Agreement (Schedule 3.1 Clause 12), all clinical treatment notes for NMK clients must:

Be completed at the time of treatment, or as soon as reasonably possible afterwards.
NMK allows a maximum timeframe of 48 hours post-treatment for completion.
Be written in English and completed to a clear, professional, and easily understood standard.
Include written evidence that verbal consent for the treatment plan and techniques was obtained prior to commencing treatment.
Be initialled and dated by the treating therapist at the time of completion.
Clearly identify the client and the services or goods provided.
Be completed and saved within MindBody. Once finalised, notes must not be deleted, edited, or altered.
If an amendment is required at a later time, the therapist must add an additional note explaining the change, including initials and date. The original entry must remain unchanged.

Consent Requirements

In addition to verbal consent documented within your SOAP notes:

Written consent is obtained for all new clients.
Written consent is renewed if 6 months or longer has passed since the client’s last visit.
Annual consent is maintained for ongoing client management.
Additional written consent is required for dry needling, myofascial cupping, and intra-oral treatment.

Minimum Clinical Information Required

Clinical notes must include sufficient detail to demonstrate professional reasoning and continuity of care. This includes:

Relevant medical and health history, including allergies, medications, illness, and referrals
Presenting conditions and symptoms
Assessment findings and baseline measures
Progress, outcomes, and observed changes

Treatment Plan Requirements

Therapists must prepare a Treatment Plan based on their professional opinion and qualifications. The Treatment Plan must:

Be appropriate to the client’s presenting condition
Consider the client’s medical history, lifestyle factors, and current symptoms
Take into account future health, mobility, and functional goals
Reflect findings from consultation and assessment

Documentation Required for Each Treatment

For every consultation, clinical notes must clearly document:

Date of service
Treating therapist
Advice and instructions provided
Referrals made or received
Examination methods and observations
Results of any testing or diagnostic procedures
Progression or sequence of treatment techniques

These standards align with Medibank Private / AHM Patient Records Standards.

Professional Accountability

Completion of accurate clinical notes is both a contractual obligation and a key component of NMK’s Professional Code of Practice.

Subject to the discretion of NMK Management, failure to meet documentation requirements may result in withholding of therapist payments and/or termination of Contractor or Employment agreements.

Advancements in technology have introduced AI-based tools that can assist health practitioners with clinical documentation. When used appropriately, these tools may support efficiency, clarity, and consistency in SOAP notes.

At NMK, AI tools may be used as documentation support tools only. They do not replace professional judgement, clinical reasoning, or the therapist’s responsibility for accurate and compliant records.

Therapist Responsibility

Regardless of whether AI is used, the treating therapist remains fully responsible for:

The accuracy and completeness of all clinical notes
Ensuring notes reflect the assessment and treatment actually performed
Maintaining confidentiality and privacy standards
Compliance with NMK documentation requirements and professional standards

AI-generated content must always be reviewed, edited, and approved by the therapist before being saved to the client record.

Acceptable Use of AI for SOAP Notes

AI tools may be used to assist with:

Structuring SOAP notes clearly and consistently
Converting brief dot points into professional clinical language
Improving clarity and readability of documentation
Ensuring all required SOAP components are addressed

AI should not be used to generate clinical decisions, diagnoses outside scope, or treatment plans without therapist input.

Approved AI Tools

The following tools may be used to assist with clinical documentation, provided NMK guidelines are followed:

ChatGPT
ChatGPT may be used as a writing assistant to help structure or refine SOAP notes. Therapists should only enter relevant clinical information and must avoid including identifiable client details.

Heidi Health
Heidi Health is a healthcare-focused AI documentation platform designed to support structured clinical note generation. Therapists must ensure outputs align with NMK documentation standards and scope of practice.

Other AI Documentation Tools
Additional AI tools may be considered as technology evolves. Therapists should consult with their Clinic Manager or the Education Team before using new platforms for clinical documentation.

Confidentiality & Privacy Requirements

When using AI tools:

Do not include full client names, contact details, dates of birth, or other identifying information
Do not upload screenshots, reports, or documents containing identifiable data
Ensure all information entered complies with privacy and confidentiality obligations

Failure to maintain confidentiality standards may result in disciplinary action.

Key Takeaway

AI tools can support efficient and professional documentation, but they do not replace clinical judgement or accountability. Therapists are expected to use AI thoughtfully, ethically, and in alignment with NMK’s professional and legal standards.