A recent case before the Administrative Review Tribunal has reignited a conversation many Occupational Therapists are already having: what does defensible documentation look like in 2025? Anything you write can travel far beyond its original purpose. A brief letter to a GP, internal correspondence between providers or a simple progress note may be bundled into evidence for plan reviews or tribunal matters. That doesn’t mean you need to write like a barrister – it means your documents should be clear, accurate, clinically reasoned and ready to stand on their own. If your name is on it, assume it could be read by a planner, a reviewer or a tribunal member.

AI in clinical documentation: policy, disclosure and quality control

AI can help polish language, summarise meetings or structure notes, but it must never replace your clinical reasoning. Set a practice policy that defines acceptable AI use, approved tools, privacy safeguards and who reviews what. Gain client consent before using any AI that processes identifiable information. If AI materially helped compile a report’s content or structure, add a short statement in the methodology section. Always perform a human quality check. Read line by line for subtle errors that can undermine credibility, such as the wrong locality, diagnosis, names or pronouns. Keep clinical thinking human – use AI to refine wording, not to decide recommendations, interpret assessments or justify funding.

Templates and human error: move from examples to prompts

Copy-over mistakes remain one of the most common credibility killers. Replace example-filled templates with prompt-based templates that cue what to write without prefilled text you might forget to change. Build forced checkpoints for person details, diagnoses and co-occurring conditions, functional impact across domains, environmental factors and risks, strategies trialled with outcomes, then specific measurable recommendations with expected benefits. A prompt-led structure reduces the chance of mixed pronouns, recycled localities or legacy goals slipping through.

Advocacy and objectivity: getting the balance right

Treating clinicians are not independent experts – and that’s fine. Your role is to provide an objective, evidence-based account grounded in therapeutic relationship and longitudinal knowledge. Be objective when describing findings and explicit when offering clinical opinion. Use neutral, neuro-affirming language about autism and other neurodivergence. Avoid deficit framing and focus on participation, function and support needs. Write to function, not labels, and connect observed performance and assessment results to everyday activities, safety and goal attainment.

Scope and funding rules: what to include and how

It is appropriate to recommend supports outside NDIS funding scope when clinically relevant – simply separate them clearly. Differentiate between recommendations you believe are reasonable and necessary under the NDIS and items that are self-funded or suited to other schemes. Explain the functional rationale for all recommendations without implying NDIS responsibility where it doesn’t apply. List co-occurring conditions where they affect function, and clarify when supports relate to the person’s ability to self-manage health conditions due to their disability.

Independent assessments and your role

When an ART matter seeks an independent opinion, the assessor will sit outside the treating team. Your task remains to produce high-quality treating-clinician documentation that summarises longitudinal observations, presents assessment data transparently, links findings to functional outcomes and risks, and shows the trials you’ve completed, the person’s response and the expected benefit from each recommendation.

Risk-aware communication and record keeping

Assume every document could be read out of context. Progress notes should be objective, free of jargon and capture consent, risks and decisions. In correspondence, state the purpose, audience and limits. If a letter is not a funding request, say so. Use version control with dates, page numbers, your credentials and contact details on every document. Protect privacy by avoiding unnecessary identifiable detail in email chains and using secure channels where possible.

A practical before-you-send sweep

Give yourself a 60-second sweep before you submit anything: confirm person details and locality, check diagnoses and co-occurring conditions, ensure functional impacts are linked to observed evidence, show what was trialled, the outcome and the risk profile, ensure recommendations are specific, measurable and prioritised with clear expected benefits, separate NDIS-funded items from other suggestions, keep language plain, respectful and neuro-affirming and confirm any AI use aligns with your policy and is disclosed if it materially shaped the document.

Key takeaways

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