Lost in ‘transcription’ - Reviewing AI Scribe Outputs

The clinician remains accountable

No matter how sophisticated the AI system, the medico-legal responsibility for the consultation notes sits with the clinician who conducted that consultation.

Any patient notes generated by an AI scribe are considered to be the clinician’s notes. Once entered into the patient’s clinical record, the notes are deemed to have been reviewed and approved by the clinician, regardless of whether the clinician has checked them or not.

This makes reviewing AI-generated documentation not just good practice, but essential professional due diligence. AI output should always be treated as a draft that requires clinical review.

A case example

Anna, a 42-year-old patient, presents for an 8-week post-operative review following a left knee arthroscopy. The surgery went well. She apologises for rescheduling several times and spends most of the consultation discussing her sick children.

As Anna is leaving, she casually mentions that she has had left calf pain for five days, “but it’s probably nothing.”

On examining Anna, you find:

• Pitting oedema in her left lower limb
• Her left calf is more than 3.5cm larger compared to the right calf
• Tenderness along the deep venous system

She has no prior DVT or family history of thrombophilia.

You appropriately diagnose and treat a likely DVT, initiate Apixaban, and arrange follow-up. Confident in your management, you rely on your AI scribe to document the consultation. The AI scribe generates a clear summary, filtering out any irrelevant noise and structures the notes well.

You later receive an Ahpra notification, and you’re surprised to find the complainant is Anna. You review her medical records and closely examine the AI generated notes.

The scribe summary (sample extract):

Several issues become apparent.

• Examination findings appear under “subjective” (e.g. pitting oedema recorded as reported by the patient)
• Symptoms are inferred or overstated (“reports calf swelling 3.5 cm larger” — the patient did not state this; this was part of the doctor’s examination)
• Workplace and location recorded (not typically required in a progress note)
• Tenderness along the deep venous system
• No record of consent for the use of AI transcription

Key takeaways

AI scribes are valuable tools, but they don’t change the fundamentals of clinical responsibility.

• AI produces summaries, not transcripts
• Errors can and do occur
• The clinician remains accountable for the record
• Every note must be reviewed, edited, and approved
• Consent and medico-legal considerations still apply

Ultimately, your clinical judgement remains the most important safeguard in the documentation process.

References

1. MDA National, Artificial intelligence tools for record management in doctor consultations. Available at: https://www.mdanational.com.au/advice-and-support/library/concise-advice/using-artificial-intelligence-tools-for-record-management-in-doctor-consultations 
2. Medical Board of Australia. Good Medical Practice: A Code of Conduct for Doctors in Australia. 2020. Available at: https://www.medicalboard.gov.au/codes-guidelines-policies/code-of-conduct.aspx

Information (including factual information) published or communicated by the MDA Group is for general information purposes only and does not constitute legal, medical or other professional advice.

Further this content is intended for education and professional development and does not replace clinical judgement, professional standards or evidence based guidelines. The information is current as at July 2026.

The MDA Group does not represent, warrant and/or guarantee that the information contained herein is free from errors, virus, interception or interference. MDA Group is not responsible for any loss suffered in connection with the use of this information. Information is only current at the date initially published.

Cases referenced or discussed by MDA Group may be based on real cases. Certain information may have been de-identified to preserve privacy and confidentiality. Members are encouraged to contact us directly for specific advice. If you are not an MDA National Member, contact your medical indemnity insurer for advice specific to your situation.