AI Virtual Scribe

Aka: AI Virtual Scribe, Automated Medical Note, AI Medical Scribe

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II. Technique: Informed Consent for AI Scribe Use

  1. Introduce the concept to the patient
    1. Cellphone or other device records the audio from the patient encounter
      1. Patient privacy is maintained (HIPAA compliant, secure, encrypted data)
      2. AI system retains data for a brief period (e.g. 30 days)
    2. AI (machine learning) software automatically transcribes and summarizes the encounter
      1. AI generates a detailed first draft of the medical note
      2. Similar to other AI-based technology (e.g. ChatGPT)
    3. Medical provider reviews the note content after it is generated
      1. Provider must approve any content that appears in the medical note
      2. Patients may also typically review their own notes in the EMR after the encounter
  2. Advantages to the patient
    1. More detailed medical note
      1. Immediate documentation is more specific and accurate than end-of-day manual documentation
    2. More time spent with the patient
      1. Less time spent out of the room for provider documentation
    3. Patient hears everything that is used to automatically generate the note
      1. Entire history, exam, assessment and plan is spoken by the medical provider
  3. Patients may decline the AI scribe (similar to declining a human scribe)
    1. Patients must consent to (verbally or written) to the use of the scribe
    2. In the future, this consent may be included in the general consent for medical care
    3. Legal requirements may vary depending on region of medical practice

III. Technique: Pearls for AI Scribe Use

  1. Expect a 6 week learning curve for providers new to AI scribe
  2. Avoid distractions after starting the AI recorder
    1. Place cellphones in do-not-disturb mode and face down
  3. Follow a consistent pattern for the encounter that will guide the documentation
    1. Ask the history of present illness and related Review of Systems
    2. Verbally review any key relevant medications, past medical history
    3. Narrate examination findings including pertinent negatives
    4. Summarize the assessment and plan
  4. Review the generated notes on the same day
    1. As with human scribes, accurate notes rely on medical provider review while encounter is fresh in memory
    2. Technical difficulties (including no recording) are more easily rectified by promptly dictating the note into AI
    3. The generated assessment and plan often needs editing, consolidation
  5. Review closely for medication errors
    1. Patient deaths have occurred with AI transcribed medication errors (e.g. Insulin 80 units instead of 8 units)
    2. Patients have accidentally received toxic medications (e.g. Chemotherapy) in place of relatively safe medications

IV. References

  1. Chaudry et. al. (2025) 20 Tips for using an AI Virtual Scribe to Document Office Visits, Family Practice Management
  2. Rotenstein (2024) JAMA Netw Open 7(5):e2413140 +PMID: 38787556 [PubMed]

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Related Topics in Medical Informatics

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