An ambient scribe hears the conversation and nothing else. History, reported symptoms and the plan as it is discussed reach the draft. The mental state examination, the formulation, the diagnosis and the risk assessment are typed.
What the draft carries, and what is typed
An ambient scribe hears what is said in the room. It does not see the patient. The observed and decided parts of the record are written by the psychiatrist whatever the draft contains.
- Drafted from what is said: presenting problem, history, reported symptoms, the plan as it is discussed, the next appointment
- Written by the psychiatrist: the mental state examination, the formulation, the diagnosis, the risk assessment, the reason for the medication decision
The mental state examination
Most of a mental state examination is seen, not said. A guarded patient, avoided eye contact, an inability to sit still: none of it produces audio.
An observation described aloud reaches the transcript and can reach the draft. Everything else is typed, and a draft that presents an examination it could not have observed is corrected before signing.
The treating clinician remains responsible for the clinical content. Clinical safety.
Medication, dose and titration
Speech recognition can mishear a number, and drug names within a class sound alike when they are said quickly. Every drug name, dose, route and frequency in the draft is read against what was decided before the note is signed.
Prescriptions are not issued or sent from aurii. The prescription is written wherever the practice writes it today, and the note records the decision and the reason for it.
Risk
A draft built from the audio carries what the patient said. The reasoning behind the decision, a collateral phone call made after the consult, and a safety plan agreed at the door are added before signing, with the timing of each one recorded.
Consults to leave uncaptured
Consent is asked before capture starts, it is recorded in the file, and it can be withdrawn at any point without a reason. Wording for that conversation, and a sheet to hand a patient, are on consent for AI scribes.
Some psychiatry work is not recorded at all, whatever the patient says.
- Assessments under a state or territory Mental Health Act, where the question is compulsory treatment
- Court-ordered and medico-legal assessments, and reports written to a brief
- A consult where the patient declines, or withdraws consent part way through
- A patient for whom being recorded is part of what is being assessed
- A family member, carer or interpreter in the room who has not been asked
The letter to the referring GP
The letter is drafted from the same consult and goes out once it is signed. What the GP needs to act on, and what stays in the psychiatrist's own file, is settled before signing. Referral letters and AI documentation.
aurii in a psychiatry consult
aurii captures a consented consult on the clinician's device and drafts the consult note and the letter to the referrer. The psychiatrist edits both and signs them.
Questions psychiatrists ask
Yes. Consent can be withdrawn at any point and no reason is needed. The psychiatrist ends the capture and writes the rest of the consult by hand.
Only the parts said aloud. Appearance, behaviour and affect are observed, and aurii captures audio, so those are typed before the note is signed.
Not in the shipped starter set. The letter templates include a specialist-to-specialist letter and a family or carer update, and the note templates that ship are general and cardiology ones. The template set.
This article is general information about clinical documentation practice, not clinical, legal or professional advice; individual obligations depend on your registration board, jurisdiction and practice context.