Quality health records in general practice
GPs might consider using an artificial intelligence (AI) scribe, which can automate parts of the clinical documentation process. AI scribes convert a conversation with a patient into a draft clinical note, summary, or letter that can be incorporated into the patient’s health record.
An AI scribe does not completely replace the work GPs undertake to prepare clinical documentation. The output of an AI scribe must be carefully checked for accuracy as these tools can produce errors and inconsistencies.
Patient consent to the use of an AI scribe must be sought at the beginning of the consultation and documented in the record.
One of the challenges of AI scribes is that they predominately only deliver free-text consultation notes and rarely populate structured data entry fields in the clinical record for observations like blood pressure or capture information in patient records like allergies and adverse reactions. Quality health records need structured data entry to generate patient information such as medicines lists, enable electronic clinical decision support, and to provide metrics and data for analysis and research. GPs using AI scribes need to be mindful that without the automatic population of data into various parts of the clinical information system, health records may be incomplete.
The RACGP resource Artificial intelligence (AI) scribes provides further information on using these tools.
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