Unexpected benefit of using AI scribes

If you are not already using an artificial intelligence (AI) scribe, it’s possible you are thinking about it, or planning to use one in the future, as our recent member survey found.  

Inevitably, some aspects of your practice will need to change as you start doing this.

AI scribes ’listen’ to your consultation and process the audio into a structured clinical note. Because you do not need to write or type during the consultation, you can direct more attention to the patient. As well as taking away some of the documentation burden for you, this offers benefits for patients as you are able focus on them more while you listen to their history and discuss their condition, treatment and management.

But if you need to carry out a physical examination, this will not automatically be picked up by the AI scribe. So how do you convey the relevant information to ensure it’s captured in the clinical note?

Your patient should already be aware that you are using an AI scribe and should have consented to its use at the start of the consultation.

You will need to consider your consultation style to best capture the physical examination. Members who have started using AI scribes, have told us the most effective way of capturing the physical examination is to say what you are doing, both before and during the examination.

Some doctors will adjust their consultation style by verbalising and ‘dictating’ their examination findings out loud so it can be captured by the AI scribe and as a memory aid. However, you will need to be mindful of your use of medical jargon in front of the patient, as this may trigger further questions from them.

Alternatively, consider using your usual approach for conducting the physical examination using plain language. That is, you might explain your examination findings as you are examining the patient (much like an OSCE) or explain to the patient your examination findings after you have completed the physical examination.

The AI scribe may be able to interpret your examination findings and record it under ’objective findings’ or ‘examination’ as a basis for your clinical note.

It is imperative you review and edit the clinical note afterwards to ensure your record accurately represents the full examination, including any positive and negative findings as well as non-verbal cues noted.

The process of verbalising the examination for the AI scribe can improve communication and patient understanding. It provides an opportunity for patients to engage with you during the examination and prompts them to ask questions.

If you verbalise your examination out loud as you go using medical jargon, make sure you manage your patient expectations and avoid unduly worrying them by adequately explaining what this terminology means. It may also help the patient if you explain why you have verbalised certain relevant positives and negatives as part of your diagnostic thought process.                      

One of the unexpected benefits of using an AI-scribe is that describing to the patient what you are doing, and why, can reduce the risk of unintended confusion or miscommunication. This is a common source of patient complaints, particularly when an intimate examination is needed. 

You are responsible for the accuracy of the final clinical note, so always review the note and make any corrections or additions before saving it to the patient’s medical record.

As with all medical records, clinical notes produced with the assistance of an AI scribe must meet the requirements of the Medical Board’s code of conduct, the Medical Benefits Schedule, Health Insurance Act and Health Insurance Regulations.

Information or aspects that may be omitted from the AI-generated note include non-verbal cues from the patient, or the results of a mental state examination. Information may also be missed, incorrectly categorised or misheard (such as names of referring doctors, medications or unusual symptoms).

Or there may be areas of sensitivity for your patient that you choose not to verbalise. An example might be a patient with an eating disorder and not highlighting their weight or BMI calculation. You may also wish to document other aspects not picked up by the AI-scribe, including trends in vital signs, such as blood pressure.

You should have a process to ensure this information is added to the final clinical note.

As well as checking the accuracy of the AI-generated note for a consultation, new information gathered, such as a chronic health condition, allergies, social and family history should be used to update or amend information in other sections of the patient’s record. 

• As the technology and integration of AI scribes improves, it promises to ease the administrative burden for doctors and improve the quality of communication and documentation.
• Using an AI scribe can support clear communication with patients and may be a good way of explaining what you are doing in an examination, and why, to avoid misunderstandings. 
• Remember though, an AI scribe is just a tool and you are responsible for its safe and effective use. So always check the generated clinical note to ensure it is accurate and complete.

Avant factsheet - Artificial intelligence for medical documentation

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