---
title: "How should an osteopath document informed consent, and can an AI scribe help? — Hanah"
description: "Osteopathic regulators in Australia, the UK and New Zealand treat consent as a conversation to record, not a form to sign. Here is what the consent part of an osteopathic note should contain, when to renew it, and which parts an AI scribe can and can't document for you."
source: https://hanah.health/blog/how-should-an-osteopath-document-informed-consent/
---

[← All posts](https://hanah.health/blog/) Article [Osteopaths](https://hanah.health/blog/osteos/)

# How should an osteopath document informed consent, and can an AI scribe help?

The Hanah team · 12 September 2026

**The short answer:** record that the patient consented, and summarise what you told them to get that consent: your working diagnosis, what you proposed and why, the material risks, the alternatives, and the patient's decision. Do it at the time, and again when the plan changes or the patient comes back after a break. An AI scribe can draft that record from the conversation, but only the parts you said out loud, and checking it is still your job.

Osteopathy has more specific guidance on this than most professions, and it's consistent across the three countries Hanah serves. Below is what the regulators ask for, a checklist for the note, a fictional worked example and a short FAQ. If you're choosing a scribe more broadly, our [guide for osteopaths](https://hanah.health/blog/ai-scribe-for-osteopaths/) covers the rest, and you can [see Hanah for osteopaths](https://hanah.health/osteos/) in action. We build Hanah, so read this with that in mind.

## What do osteopathic regulators ask you to record?

The three regulators agree on the essentials. Consent is an ongoing process rather than a signature, and the record should show the conversation, not just the outcome.

-   **Australia.** The Osteopathy Board of Australia's [Informed consent: Guidelines for osteopaths](https://www.osteopathyboard.gov.au/documents/default.aspx?record=WD13%2f10346&dbid=AP&chksum=7tRZKLW3xAsTiGaAh6DutQ%3d%3d) (2013) are still listed on the Board's [codes and guidelines](https://www.osteopathyboard.gov.au/Codes-Guidelines.aspx) page. A signed form isn't a legal requirement, but your notes should record that consent was given, with a summary of the information you provided. The guidelines say contemporaneous notes can be as effective as a consent form, and that a form handed to the patient by reception before the consultation isn't valid evidence of informed consent. Section 4.2 of the [shared Code of conduct](https://www.ahpra.gov.au/Resources/Code-of-conduct/Shared-Code-of-conduct.aspx) adds that you should consider written consent for procedures that are higher risk or could cause serious injury or death.
-   **United Kingdom.** General Osteopathic Council standard [A4](https://www.osteopathy.org.uk/for-osteopaths/osteopathic-practice-standards-ops/comms-patient-partnership/) asks you to record the key elements of the discussion: the information discussed, the patient's concerns and questions, how you addressed them, and the decisions made. Written consent must be obtained, and kept with the records, for any vaginal or rectal examination or technique. Where you examine and treat at the same time, A4 describes explaining your approach, the kinds of technique you might use, the limits you'll work within and how the patient can ask you to stop.
-   **New Zealand.** The Osteopathic Council's [Informed consent guidelines](https://www.osteopathiccouncil.org.nz/common/Uploaded%20files/Publications/Policies%20and%20Guidelines/Guidelines%20informed%20consent%2022-12-14.pdf) (2014) make the same points as Australia's about forms and summaries. Its [Guidelines for Clinical Record Keeping](https://www.osteopathiccouncil.org.nz/common/Uploaded%20files/Publications/Policies%20and%20Guidelines/Gdlnes%20Clncal%20Recrd%20Kpping.pdf) ask for informed consent to be noted for all procedures.

## What should the consent part of the note include?

Drawing on those documents, a consent entry that would stand up to scrutiny usually covers:

-   **The working diagnosis**, explained in words the patient understood.
-   **What you proposed and why**: the examination, the techniques and the regions.
-   **The risks you discussed**: common side effects, and any low but serious risks of the particular technique.
-   **That you screened for contraindications.** The Australian and New Zealand guidelines list this among the things patients want to know.
-   **The alternatives**, including other techniques, deferring treatment or not treating.
-   **Cost**, where it came up. The Australian and New Zealand guidelines both include it.
-   **The patient's questions** and your answers.
-   **The decision**: agreed, declined, or agreed to part of the plan, with any limits the patient set.
-   **Sensitive areas**: the explanation, the offer of a chaperone, and anyone else in the room. GOsC standard [C2](https://www.osteopathy.org.uk/for-osteopaths/osteopathic-practice-standards-ops/c-safety-and-quality-in-practice/) asks you to record the patient's consent to an observer's presence.

## When do you need to renew consent?

The Australian and New Zealand guidelines say consent should be repeated when a patient returns after a period of absence and when their condition or treatment plan changes, and that it should happen as close as possible to the treatment itself. The GOsC treats consent as ongoing throughout care, and says you must stop if the patient is concerned you're going beyond what was agreed.

In practice, a new technique, a new region or a new presentation means a new consent entry.

## Can an AI scribe document consent for you?

It can do much of the writing. It can't do the consenting, and it can't record what never reached the microphone.

Here is where a scribe helps, using Hanah as the example:

-   **It captures the conversation you actually had.** If you explain the technique, the risks and the alternatives aloud, the draft can summarise them. That is closer to what the regulators describe than a tick-box.
-   **Consent can have its own slot.** Hanah's templates are editable, and each fill-in slot can carry an instruction. A Consent slot that asks for the techniques explained, the risks discussed, any alternatives offered and the patient's decision gives you a consistent entry every visit.
-   **Gaps stay visible.** Hanah's drafting rules limit clinical facts to the current session, and a slot that wasn't discussed is left out rather than filled with a guess. If the Consent section is missing from a draft, treat that as a prompt to check, not something to fill in from memory.
-   **Last visit's consent isn't copied forward.** When Hanah drafts a progress note, it uses the last note from the same template for that patient as a guide to structure. The clinical facts have to come from today's session, so the consent entry reflects today's conversation, or nothing.

And here is what no scribe can do:

-   **Hear a nod.** Non-verbal agreement doesn't appear in a transcript. Say the decision out loud, or add it when you review.
-   **Judge validity.** Whether the patient had capacity and agreed freely is your clinical judgement.
-   **Replace written consent** where it's required.
-   **Take responsibility.** Ahpra's [guidance on AI in healthcare](https://www.ahpra.gov.au/Resources/Artificial-Intelligence-in-healthcare.aspx) and the GOsC's [AI guidance](https://www.osteopathy.org.uk/for-osteopaths/practice-guidance/artificial-intelligence/) both leave you accountable for what an AI tool writes into the record.

One more thing: the note, not the recording, is your evidence. The recording is how the draft gets written; the note is what goes into the record, so it needs to carry the consent on its own.

## Do you need consent to use the scribe itself?

Usually, yes. Ahpra's AI guidance says a generative-AI scribe will generally need the patient's informed consent, ideally noted in the record, and that consent matters before a consultation is recorded. The GOsC asks you to be able to explain the tool and what happens to the patient's information, and to mention transcription in your privacy notice. In New Zealand, the Council's record-keeping guidelines already ask for consent about data collection and storage from every new patient.

Ask before you press record. Patients tend to ask where the recording goes, how long it's kept and whether anyone trains AI on it. Our [data processing agreement](https://hanah.health/dpa/) and the Trust Centres for [Australia](https://hanah.health/au/trust/), [New Zealand](https://hanah.health/nz/trust/) and the [UK](https://hanah.health/uk/trust/) answer those questions for Hanah.

## A worked example

This is fictional. A new patient in her late thirties has neck and upper back pain after long hours at a desk. After the history and examination, part of the conversation goes like this:

> **Osteopath:** From what I've found, this looks mechanical: the joints and muscles around the base of your neck and upper back. I'd suggest soft tissue work and gentle articulation there. I could also add a manipulation technique to the upper back. Some people feel sore or tired for a day or two afterwards. Manipulation has some small risks of its own, which I can go through if you'd like to consider it. The screening tests I did earlier were clear. The fee is the same either way.
> 
> **Patient:** Is manipulation the clicking one? I'd rather not today.
> 
> **Osteopath:** That's fine. Soft tissue and articulation only, then. Tell me at any point if you'd like me to stop.
> 
> **Patient:** Okay, go ahead.

A Consent entry drafted from that exchange might read:

> **Consent:** Working diagnosis explained (mechanical neck and upper back pain). Proposed soft tissue and articulation to the cervical and thoracic spine; thoracic manipulation offered. Discussed possible soreness or tiredness for 1–2 days. Contraindication screening clear. Fee discussed. Patient declined manipulation today. Verbal consent to soft tissue and articulation; advised she can stop treatment at any time.

Notice what depended on the words being spoken. If she had nodded instead of saying "okay", the decision would be missing from the draft. Adding it is a job for your review, and it's why the review matters.

## FAQ

**Do I need a signed consent form?** In Australia and New Zealand, the osteopathic consent guidelines say there's no legal requirement for one, and that a signature alone doesn't prove consent was informed. Ask your indemnity insurer about forms for specific risks. In the UK, written consent is required for vaginal or rectal examination or techniques.

**Is a consent form at reception enough?** No. The Australian and New Zealand guidelines both say a form signed before the consultation isn't valid evidence of informed consent.

**Do I have to re-consent every visit?** Not necessarily, but the guidelines say to renew consent after a period of absence and whenever the condition or plan changes. A short entry each time is easier to defend than silence.

**Can I keep the audio as proof?** Don't rely on it. The note is what goes into the record, so make sure it carries the consent on its own.

If you'd like to see a Consent slot working in a real template, [see Hanah for osteopaths](https://hanah.health/osteos/) or book a demo below.

[Hanah for osteopaths →](https://hanah.health/osteos/)

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