AI Scribe is designed to streamline documentation and improve efficiency during patient encounters. Following these best practices will help ensure accurate data capture, maintain compliance, and support a smooth clinical workflow.
Before the Exam
Obtain Informed Consent (Required)
Before starting any AI Scribe session, inform the patient that an AI transcription tool will be used during their visit. Obtain their verbal or written consent and document it in the patient record prior to beginning the exam.
During the Exam
Verbally Reference Each Test by Name
For AI Scribe to correctly capture and place exam data, clearly state test names and results aloud as you perform them.
Examples:
- “You are seeing 20/20 in your right eye.”
- “Pressure in your right eye is 14.”
Speaking naturally while including these verbal cues ensures accurate data routing within the record.
Review and Save Exam Data Promptly
Review AI Scribe-generated exam data as soon as possible after the encounter while details are still fresh.
If immediate review isn’t feasible, data can be reviewed later at your convenience. To improve efficiency, you can filter results to focus only on data that differs from the patient’s previous exam, helping you quickly identify meaningful changes.
After the Exam — Before Signing
Use the Transcript as a Verification Tool
The AI Scribe transcript remains available until the exam is signed. Use it as a reference to:
- Verify accuracy
- Confirm completeness
- Ensure all test data was captured correctly
Review and Reconcile Documentation
Before signing, compare the completed exam record against the transcript. This step helps ensure nothing was missed and that all documentation is accurate.
At Signature
Finalize Only After Complete Review
Do not sign the exam until the record has been fully reviewed and verified.
Important: The AI Scribe transcript is permanently deleted once the doctor signs the exam and cannot be recovered. Ensure all documentation is complete and accurate before applying your signature.
Key Takeaway
Follow this simple workflow to maximize accuracy and efficiency:
Consent first → Name tests aloud → Review data promptly → Use transcript to verify → Review thoroughly → Then sign