Top 10 Tips for using AI scribe technology in your consultations

Pre consultation

1. Prepare your workflow

• Configure your AI scribe tool with templates that align with your consultation style and documentation preferences.
• Use standardised note structures (e.g. SOAP: Subjective, Objective, Assessment, Plan) where appropriate, tailored to your practice and patient cohort.
• Test outputs to ensure summaries are clinically useful and appropriately detailed.

2. Obtain informed consent:

• Inform patients about the use of AI scribe technology prior to the consultation, including an explanation of how it works, how patient information is used and protected, and the risks and benefits.
• Incorporate consent into your practice workflows (e.g. website, booking system, signage, and patient materials.
• Obtain and document verbal consent before using an AI scribe during a consultation. Prompts within the tool can assist with this process.
• Establish a clear alternative process for patients who decline the use of AI scribes.

3. Understand your tools and its limitation:

• Familiarise yourself with how your AI scribe captures, processes, and generates summaries.
• Be aware of limitations such as transcription errors, missing context, or incorrect clinical interpretation.
• Avoid over-reliance on outputs, clinical judgement must always take precedence.

During the consultation

4. Verbalise nonverbal findings

• Clearly articulate relevant findings, impressions, and decisions during the consultation, including noting non-verbal observations where appropriate.
• This supports more accurate and complete AI-generated documentation.

5. State your clinical reasoning

• Verbally outline differential diagnoses, clinical reasoning, and management plans.
• This helps ensure the AI-generated record reflects your decision-making process.

6. Maintain patient engagement

• Maintain eye contact, active listening, and clear communication throughout the consultation, and be transparent when the tool is being used in real time.
• This ensures the use of AI technology does not detract from patient interaction.

Post consultation

7. Review and edit transcription

• You remain responsible for the accuracy and completeness of the medical record.
• Carefully review the AI-generated summary before incorporating it into the patient record.
• Edit as required to ensure clinical accuracy, relevance, and completeness.

8. Transfer records appropriately

• Ensure the summary is correctly and securely transferred into your Electronic Medical Record (EMR).
• Confirm that information is filed under the correct patient and consultation.
• Follow your organisation’s data handling and record-keeping protocols.

9. Manage and store data securely

• Understand where and how transcription data is stored by the AI provider.
• Delete or archive recordings in line with privacy requirements, contractual obligations, and practice policies.
• Ensure compliance with relevant privacy legislation, the Australian Privacy Principles, and data security standards.

10. Regularly review and update your processes

• Periodically review how AI scribes are used in your practice.
• Update workflows, consent processes, and safeguards as technology evolves.
• Provide training and support for clinicians using these tools.

AI scribe technology can enhance efficiency, but it does not replace clinical judgement or professional responsibility. Practitioners are always accountable for the accuracy, completeness, and security of their records. As clinical best practice evolves, if you have robust processes and active oversight you can reduce medico-legal risk and ensure safe, high-quality patient care.

More resources:

• Concise advice: Using Artificial Intelligence (AI) tools for record management in doctor consultations
• eLearning: AI scribe tools in record management
• On-demand recording: Using AI tools for record management in doctor consultations
• AI Governance policy & checklist: Coming soon!

References:

1. Australian Institute of Digital Health, Implementation of AI Scribes in healthcare workflows, June 2025 https://digitalhealth.org.au/wp-content/uploads/2025/07/Implementation_AI-scribes-in-healthcare-workflows.pdf

2. Knibbs J, How many GPs are actually using AI scribes?, Health Services Daily, May 2020 https://www.healthservicesdaily.com.au/how-many-gps-are-actually-using-ai-scribes/45549

3. MDA National, Using Artificial Intelligence (AI) tools for record management in doctor consultations, Nov 2023 https://www.mdanational.com.au/advice-and-support/library/concise-advice/using-artificial-intelligence-tools-for-record-management-in-doctor-consultations

   
   

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