AI documentation accuracy: what to check on every draft

A draft is wrong in one of two directions: content that was discussed is missing, or content that was never discussed is present.

An omission is caught by the clinician who remembers saying the thing that is not there. An inserted line sits under the expected heading, in the register of the lines around it, and nothing in its phrasing signals that it was never said.

• 1. Identifiers and encounter. Confirm the patient, the date and the encounter first. A draft filed against the previous consultation carries every correction into the wrong record.
• 2. History against what was asked. Read the history for symptoms nobody raised. A familiar presentation brings a familiar cluster of questions with it.
• 3. Attribution. Where a parent, carer or interpreter spoke, check whose account each line records. A carer's account can arrive as the patient's own words.
• 4. Examination findings. Every line under the examination heading describes something you examined. A reported symptom promoted to a finding asserts an observation never made.
• 5. Negative findings. Add the negatives you checked without saying aloud. Audio holds only what was spoken.
• 6. Laterality and site. Check left and right, and the side, vessel, joint or level named in any procedure. A wrong side runs consistently through the draft.
• 7. Medications. Read every drug name, dose, route and frequency against the chart or the script. Names that sound alike survive transcription intact.
• 8. Numbers and dates. Check observations, results, gestations, intervals and durations against their source. A transposed digit reads as a plausible value.
• 9. Empty headings. A heading with nothing under it reads to the next clinician as a section considered and found unremarkable.
• 10. The plan. Check the follow-up interval, referral urgency and safety-netting advice against what was agreed. A draft can widen a two-week review into a routine one.
• 11. Certainty. What was hedged in the room stays hedged on the page. A possibility can appear as the working diagnosis.
• 12. Anything you cannot place. Delete a sentence you cannot trace to a moment in the consultation. Softening it leaves an unsourced assertion in a signed record.

A drafted note becomes the record at the signature. Ahpra and the National Boards require the entry at the time of the consultation or as soon as practicable afterwards, whether it was typed or drafted by software.

Where the review cannot happen before the next patient, the draft waits until it is read.

A written policy names who reviews a draft, states that no note is finalised without a named clinician's signature, and keeps the draft and the signed version distinct in the record.

Sampling signed notes against their drafts at a set interval shows which of the twelve checks a team is missing. Clinical audit of AI-generated notes.