Accurate, honest and defensible health records under New Zealand law and your responsible authority's standards
3CPD hours
20final questions
80%pass mark
PDFcertificate
What you will learn
Identify the Acts, regulations and codes that govern clinical records in New Zealand, including the HPCA Act 2003, the Code of Rights, the Privacy Act 2020, the HIPC 2020 and the Health (Retention of Health Information) Regulations 1996.
Locate and apply your own responsible authority's record-keeping standard.
Write entries that record history, findings, reasoning, plan, information given, consent, safety-netting and follow-up.
Use clear, objective, respectful and culturally safe language that separates observation, reported information and opinion.
Make late entries and corrections that are transparent, signed and correctly dated, without altering earlier entries.
Use electronic records, templates, telehealth, messaging and AI scribe tools safely and accountably.
Respond correctly to access requests under HIPC rule 6, including the 20 working day timeframe and limits on charging, and to correction requests under rule 7.
Apply the 10-year minimum retention period and plan secure storage, transfer, practice closure and disposal.
Protect the integrity of records after a complaint, adverse event or death, and respond appropriately to the HDC, your authority or a coroner.
Demonstrate insight and build a measurable remediation plan if a documentation concern is raised.
About this course
This course covers clinical record keeping for registered health practitioners in Aotearoa New Zealand: what a good entry contains, how to write clearly and respectfully, how to make late entries and corrections honestly, how to work safely in electronic records and with templates, telehealth and AI scribes, and how the Health Information Privacy Code 2020 shapes access, correction, retention, security and disclosure.
It is written for doctors, nurses, midwives, oral health practitioners, pharmacists, physiotherapists, psychologists, paramedics and other practitioners regulated under the Health Practitioners Competence Assurance Act 2003, whether you want to strengthen everyday practice or you are responding to a concern raised about your records by an employer, the Health and Disability Commissioner or your responsible authority.
In New Zealand, records are the first thing examined when care is questioned: by the HDC against the Code of Rights, by responsible authorities and Professional Conduct Committees, by the Health Practitioners Disciplinary Tribunal and by coroners. Good documentation protects the people in your care and is the strongest evidence of the care you gave. This course shows you how to meet that standard every day and how to show insight and remediation if a concern arises.
Course facts
CPD value
Approximately 3 CPD hours (estimated learning time including knowledge checks, reflection and assessment)
Audience
Registered health practitioners in New Zealand under the HPCA Act 2003, including doctors, nurses, midwives, oral health practitioners, pharmacists and allied health practitioners
Standards covered
HPCA Act 2003; Code of Health and Disability Services Consumers' Rights (Rights 4–7); Privacy Act 2020; Health Information Privacy Code 2020 (rules 5–11 and rule 3A); Health (Retention of Health Information) Regulations 1996; Public Records Act 2005; Health Act 1956 s 22F; MCNZ Patient records (2020); Nursing Council Code of Conduct; Midwifery Council Code of Conduct; Dental Council Patient records and privacy of health information practice standard (2020); Pharmacy Council Code of Ethics 2018
Format
Self-paced, gated lessons with knowledge checks, case studies and reflection
Assessment
20 scenario-based questions, 80% to pass (16 of 20)
Outcome
Certificate of completion and a written reflection for your CPD record
Alignment
Mapped to the record-keeping standards of the Medical Council, Nursing Council, Midwifery Council, Dental Council, Pharmacy Council and other HPCA Act responsible authorities, and to HDC and Privacy Commissioner expectations
Syllabus
10 sections, 3 CPD hours, 20-question final assessment
1The clinical record in Aotearoa New Zealand: purpose and framework3 lessons
Why the clinical record matters
The legal and regulatory framework
What each regulator expects
2What a good record contains3 lessons
The content of a clinical entry
Clear, objective and respectful writing
Recording communication, consent and decisions
3Timing, late entries and alterations2 lessons
Contemporaneous records and late entries
Correcting errors without altering the record
4Electronic records and digital tools3 lessons
Working safely in electronic health records
Templates, copy-forward and auto-populated text
Telehealth, messages, recordings and AI scribes
5Access, correction, retention and security of records3 lessons
The person's right to access their health information
Requests to correct a record
Retention, transfer, closure and disposal
6Records in complaints, HDC, coronial and regulatory processes3 lessons
Who reads your records when something goes wrong
Your records after a complaint or incident
Documentation failings reviewers commonly find
7When documentation falls short: outcomes, insight and remediation3 lessons
How regulators respond to documentation concerns
Showing insight and remediating documentation
Building documentation habits that last
8Conclusion and key points1 lesson
Conclusion and key points
9References and further reading1 lesson
References and further reading
10Your reflective account1 lesson
Your reflective account
Who this course is for
Registered health practitioners in New Zealand under the HPCA Act 2003, including doctors, nurses, midwives, oral health practitioners, pharmacists and allied health practitioners.
Continuing professional development record for your portfolio.
Your name, the course title and the CPD hours
Completion date and a unique certificate ID that can be verified
Downloads as a PDF; save it to your portfolio
Fitness To Practice
Certificate of Completion
This certifies that
Your Name
has successfully completed
Clinical Documentation and Record Keeping
Completed12 Oct 2026
3CPD hours
Certificate IDFTS-7Q4K-2M9X
Continuing professional development record — New Zealand
Questions about this course
How long must health records be kept in New Zealand?
The Health (Retention of Health Information) Regulations 1996 require you to keep records for 10 years or more, starting the day after your last service to that person, unless it has been transferred to another provider or given to the patient or their executor. Public health agencies also follow the Public Records Act 2005. The course covers storage, transfer and disposal.
How do I make a late entry or correct a clinical note properly?
A late entry should be clearly labelled, show the date and time it was written as well as the time of the events, and be signed. Earlier entries must never be altered or deleted. The course explains why transparent corrections protect you and why concealed changes turn a documentation issue into a probity concern.
Does the record keeping course cover AI scribes and templates?
Yes. Section 4 covers electronic records, templates, telehealth, messaging and AI scribe tools, and how to use them safely and accountably. You remain responsible for every entry made in your name, which is why the course has you check, correct and sign off AI-drafted notes and avoid copy-forward errors.
Which record keeping standards does the course map?
Each authority's rules are mapped: the Medical Council's 2020 statement on patient records, the clear-and-accurate records duty in the Nursing Council Code of Conduct, the 2020 Dental Council records and privacy standard, midwives' record-keeping duties in their code, and the Health Information Privacy Code 2020, so you can locate and apply your own authority's standard.
What do I receive after passing the clinical record keeping course?
Score 16 or more out of 20 (80%) in the final test and you receive a 3-hour certificate plus a structured reflective account, which can support your recertification where relevant to your development plan. The course costs NZ$139, is self-paced online and is independent of any council.
The Privacy Act 2020 and HIPC 2020 rule by rule, including new rule 3A, serious-threat disclosures, digital confidentiality and responding to privacy breaches.
Honest communication when care goes wrong: HDC open disclosure guidance, the HQSC adverse events policy, ACC treatment injury and culturally safe apology.