What an AI medical scribe does

Six stages run from the start of the consult to a document leaving the practice.

• Consent: the patient agrees before recording starts.
• Capture: a phone, tablet or laptop records the consult in the room or at the bedside.
• Transcript: speech recognition converts the audio to text.
• Draft: a model writes the note, the letters and the discharge summary from the transcript and the template.
• Review: the clinician reads each draft against the consult and corrects it.
• Signature: the clinician signs, and the signed document is filed, sent or billed.

One transcript produces more than one document: the note and the letter to the referring doctor are drafted from the same consult.

A vendor's privacy notice states which service holds the audio, the transcript and the draft. Audio retention is a configuration setting, set before the first consult.

A scribe drafts documentation. It does not examine the patient, reach a diagnosis or choose a treatment.

Speech recognition mishears drug names, doses and numbers, so those fields are checked against the source before the document is signed. Background noise, distance from the microphone and a consult in more than one language reduce what the transcript contains. A fluent draft can still be wrong.

The draft carries only what was said out loud. Examination findings and reasoning that stayed in the clinician's head are added at review or they are absent from the record.

The treating clinician remains responsible for the clinical content. Clinical safety.

Recording a consultation collects health information, so the patient is told before recording starts and agrees to it. Verbal consent noted in the record is the common form, some hospitals and practices require it in writing, and local policy decides. A patient can decline, and the consult proceeds without a recording.

A family member, carer or interpreter in the room is recorded too. Wording for the start of a consult is in the consent guide, and the patient explainer is written to be handed over.

• Where do the audio, the transcript and the drafted document sit, and where are the backups?
• Is patient content used to train models, and is that in the contract?
• Can anything be filed, sent or billed before a clinician signs it?
• What is written to the audit trail, and how long is it kept?
• What is deleted when the practice leaves, and what is kept?
• Which delivery networks can it send correspondence to, and can it receive results?

A longer set is at evaluating an AI scribe.

Clinical audio and the documents drafted from it are health information under the Privacy Act 1988 (Cth), the sensitive category of the Australian Privacy Principles, which govern consent, use, disclosure and the patient's right of access and correction. State health records legislation applies as well in New South Wales, Victoria and the Australian Capital Territory.

The record must be accurate and contemporaneous whatever produced the draft. AI scribes and Ahpra obligations.

• OAIC: the Australian Privacy Principles
• OAIC: health information and your privacy rights