Do not sign an AI-generated clinical note as if it were verified. Treat it as a draft: confirm the patient and encounter, compare every clinically meaningful statement with what actually happened and with relevant chart context, correct omissions and invented details, then complete the normal sign-off only when the record reflects your own judgment. The American Psychological Association’s preliminary guidance says clinicians must review AI-generated documentation for accuracy and edit it as needed before signing; it also stresses that clinicians remain responsible for documentation accuracy and clinical decisions. The guide is written for psychologists, so apply your profession’s rules, institutional policy and local law as well.
A fluent note can still contain a dangerous transformation. An AI scribe has changed a planned prostate examination into an examination documented as performed, and has turned a conversation about a patient’s hands, feet and mouth into a diagnosis of hand, foot and mouth disease. These are not proofreading mistakes. They change what the record says happened and what the clinician concluded.
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The rule before every signature
An AI-generated note is a proposed account of an encounter, not an authoritative account. Your signature makes the final documentation part of the clinical record, so review is a clinical and professional responsibility rather than an optional quality check. The APA’s guidance for evaluating AI scribes, created in December 2025 and last updated in January 2026, states: “You must review AI generated documentation for accuracy and edit as needed prior to signing and the documentation becoming part of the clinical record.” It describes itself as preliminary and non-exhaustive; it does not replace rules for another profession or jurisdiction.
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1Clear out junk files and repair common Windows errors2Scan for outdated or missing drivers - takes under a minute3Repair Windows errors before they cause bigger problemsUse the generated text to save drafting time, but make the final note your own clinical document. If you cannot verify a statement, remove it or rewrite it to reflect the uncertainty that was actually present. Never let polished prose, a high confidence score or a familiar template substitute for checking the encounter.
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Why an apparently good note can be wrong
AI can change an action or its timing
Speech-recognition and summarization systems may collapse future, conditional and completed actions into one tense. “We will order an MRI” can become “MRI ordered.” “Examination discussed” can become “examination performed.” A plan to administer a vaccine can be rendered as an administration record. These changes affect care coordination, billing, quality reporting and medico-legal interpretation.
AI can infer a diagnosis that was never made
In a March 18, 2024 report, the American Medical Association described a scribe that interpreted discussion of a patient’s hands, feet and mouth as hand, foot and mouth disease. The words were present, but the diagnosis was not. Similar errors can arise when a patient mentions a family member’s illness, a differential diagnosis, a rule-out condition or a symptom that belongs to another person.
AI can omit the detail that makes a statement safe
A draft may leave out laterality, dose, timing, source of information, severity, a negative finding or a qualification such as “patient declined.” An omitted qualifier can turn a cautious assessment into an absolute one. Review what is missing as deliberately as what is present.
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The following sequence is a practical synthesis of the APA recommendations and the AMA error examples. It is not a validated scoring instrument or a universal protocol. Adapt it to your specialty, EHR and local policy.
- Identify the record. Confirm the patient, date, encounter type, authoring clinician and intended note template. Check that the draft is attached to the correct visit and not to a telephone call, cancelled appointment or another family member’s chart.
- Reconstruct the encounter. Use your memory, contemporaneous prompts, the transcript or dictation available to you, orders and relevant chart context. Do not rely on the generated note alone to tell you what happened.
- Verify clinically meaningful facts. Check symptoms, history, examination findings, test results discussed, assessment, treatment, medications, safety advice and follow-up. Review the sections that drive decisions first.
- Inspect verbs and time words. Look for planned, recommended, considered, scheduled, declined and pending versus performed, completed, administered, confirmed and ruled out.
- Challenge conclusions. Remove diagnoses, negative findings, causal explanations and certainty levels that were not supported by the encounter. Confirm that a quoted patient statement is actually a quote or label it as a paraphrase.
- Repair omissions and irrelevant text. Add details needed for continuity and remove copied material, unrelated conversation and speculation. If a fact cannot be established, leave it out rather than filling the gap from a template.
- Save in the intended record and sign normally. Verify that edits were committed to the correct note, that required fields are complete and that your organization’s co-signature, addendum or attestation workflow has been followed.
Audit the note section by section
| Note area | What to verify | Common correction |
|---|---|---|
| Reason for visit and history | Who reported the information, the chief concern, onset, duration, severity, triggers, relevant negatives and the patient’s stated goals. | Restore a missing timeframe or attribute a statement to a caregiver rather than the patient. |
| Medications and allergies | Current medication, dose, route, frequency, recent changes, adherence and reaction details; distinguish a medication discussed from one prescribed. | Delete a medication the patient merely mentioned and correct a dose or allergy status against the medication list and encounter. |
| Examination and observations | Only findings actually observed or measured, including laterality, location, vital signs and the method or limitation of the examination. | Change “normal examination” to the specific observed finding, or remove an examination that was planned but not done. |
| Tests and results | Whether a test was ordered, collected, reviewed or still pending; include the source and date of a result when relevant. | Separate a result reviewed during the visit from a test ordered for later. |
| Assessment | The clinician’s differential, working diagnosis, reasoning and level of certainty, without converting a possibility into a confirmed condition. | Replace an inferred diagnosis with the symptom or concern actually documented. |
| Plan and orders | Medication instructions, referrals, education, precautions, follow-up interval, patient agreement or refusal, and who is responsible for the next action. | Change “will consider referral” to “referral placed” only when it was actually placed; otherwise retain the conditional wording. |
Catch action, timing and certainty errors
Read every sentence containing an action, result or conclusion as if another clinician will act on it without hearing the visit. The table below gives a focused language check.
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| If the encounter said | The draft must not silently become | Safer edit |
|---|---|---|
| “Discussed colonoscopy; patient will decide” | “Colonoscopy scheduled” | “Colonoscopy discussed; patient will decide” and record any agreed follow-up. |
| “Consider starting an SSRI if symptoms persist” | “SSRI started” | Keep the conditional plan and document the trigger for reconsideration. |
| “Patient reports penicillin rash as a child” | “Penicillin allergy confirmed” | Preserve the reported history and reaction details; follow your allergy-reconciliation policy. |
| “No chest pain today” | “Cardiopulmonary examination normal” | Document the symptom denial separately from examination findings. |
| “Rule out appendicitis” | “Appendicitis diagnosed” | Record the differential and the evidence supporting or arguing against it. |
| “Patient declined blood draw” | “Labs obtained” | Document the refusal, discussion and any alternative plan. |
Also inspect pronouns and attribution. A system may merge the patient’s words with the clinician’s assessment, or attach a caregiver’s history to the patient. Correct the speaker, source and tense wherever the distinction affects care.
Check omissions as carefully as hallucinations
Start with the decisions made during the visit and work backward: What did you decide, and what facts justify that decision? Confirm that the note contains the relevant symptom history, examination evidence, test information, patient preferences and follow-up instructions. A short note can be accurate; a long note can be unsafe if it buries the decisive fact or leaves out a limitation.
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- Look for missing laterality, body site, dose, route, frequency, duration or stop date.
- Confirm that abnormal findings and clinically important negatives are present when they informed the assessment.
- Check that patient refusal, inability to complete an examination, interpreter use, communication barriers and safety-net instructions are recorded when relevant.
- Remove generic normal findings that were not assessed. A template’s unchecked normal review is not evidence that the examination occurred.
- Ensure follow-up has an interval and a responsible party when the plan requires one.
Do not “complete” a gap by guessing what usually happens in that template or specialty. If the encounter did not establish a fact, use an explicit limitation or omit the claim according to your documentation policy.
Correct the draft without creating a second error
Edit for truth, not style alone
Correct the clinical content before polishing grammar. Preserve the patient’s meaning and your reasoning; do not make the note sound more certain or more comprehensive than the visit. When you replace generated language, ensure the new wording is supported by the encounter and that a downstream reader can tell what was actually done.
Keep provenance and required attestations
Follow your EHR’s rules for identifying the author, documenting an addendum and retaining a transcript or source note. Do not paste an unreviewed transcript into the permanent record merely to preserve it. Conversely, do not delete source material if your policy requires retention for a defined period. The correct retention, access and audit trail depend on your organization, product and jurisdiction.
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Prevent copy-forward contamination
Compare dates and values with the current encounter. Remove stale medication lists, old symptoms, resolved diagnoses and prior examination findings that the AI carried forward. If a historical fact remains relevant, label it as historical rather than presenting it as today’s observation.
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Privacy, security and patient notice
AI scribes may use ambient listening, clinician dictation or an uploaded written summary. They may send content to proprietary or third-party language models and may connect directly to the EHR or operate as a separate application. The APA advises assessing privacy compliance, security, data handling and minimization, then creating a consent process and documentation policy suited to the practice.
Questions to answer before deployment
- What audio, transcript, note and metadata are collected, and for how long?
- Where are data processed and stored, who can access them, and what vendor subprocessors are involved?
- May practice data be used to train or improve a model, and can that use be disabled?
- How are records encrypted, deleted, exported and audited?
- What happens when the system is unavailable, misidentifies a speaker or sends content to the wrong chart?
- How will patients be informed, how will consent or refusal be recorded where required or adopted as policy, and what alternative documentation process is available?
There is no single federal rule that resolves disclosure for every ambient-documentation setting. The AMA Journal of Ethics analysis explains that legal informed-consent duties depend on context and that ethical disclosure considerations may be broader. It also discusses privacy risks, inaccurate transcription, accent-related errors and distortions introduced when a system summarizes or infers from conversation. Treat that discussion as ethics commentary, not individualized legal advice; consult applicable law, your compliance team and institutional policy.
Assess an AI scribe before expanding its use
Choosing a tool is part of documentation safety. Compare products and configurations on the dimensions below rather than treating “AI scribe” as a single capability.
| Dimension | Questions for evaluation |
|---|---|
| Workflow fit | Is it built into the EHR, connected through an API or standalone? Can it use your note templates without manual re-entry? |
| Input method | Does it use ambient listening, clinician dictation, an uploaded summary or several modes? What happens when multiple speakers talk? |
| Accuracy and edit burden | Which errors occur in your specialty, how often do clinicians correct them and how long does review take for typical visits? |
| Privacy and security | What compliance commitments, access controls, retention limits, encryption, subprocessors and model-training restrictions apply? |
| Consent and transparency | Can the practice explain the tool in plain language, record consent or refusal and offer a non-recording workflow? |
| Practice fit | Can you customize terminology, languages, templates and specialty requirements? What training, support and downtime procedures are provided? |
In its 2024 implementation report, the AMA said The Permanente Medical Group considered accuracy, ease of use and training, privacy and security, and patient consent. Its later report identified weak template integration and perceived editing burden as barriers for some clinicians. A tool that produces a good first draft but requires extensive correction may not reduce total work or risk in your setting.
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What the reported benefits do—and do not—show
The Permanente Medical Group’s evaluation, reported by the AMA on June 12, 2025, covered 63 weeks from October 2023 through December 2024, involving 7,260 physicians and 2,576,627 patient encounters. The organization estimated 15,791 documentation hours saved. In the same deployment, 84% of surveyed physicians reported a positive effect on communication and 82% reported improved overall work satisfaction; 47% of patients said their doctor spent less time looking at the computer, while 39% said the doctor spent more time speaking directly with them.
Those figures describe one organization’s implementation and survey results, not a guaranteed saving or quality effect for every specialty, practice or product. They also do not remove the need for clinician review. As TPMG’s Kristine Lee, MD, put it, “We have an opportunity and obligation to take advantage of innovative AI that improves patient care and augments our physicians’ capabilities, while supporting their wellness.” Vincent Liu, MD, MSc, said, “Both doctors and patients highly value face-to-face contact during a visit, and the AI scribe supports that.” The benefit is realized only if the saved time is not offset by unsafe editing, overlooked errors or unworkable governance.
Failure modes and recovery actions
The wrong patient or visit is selected
Stop editing, detach or discard the draft according to policy, and report the misfiled content through the appropriate privacy and safety channel. Recreate the note in the correct encounter; do not rely on copy-and-paste to repair the audit trail.
A planned action appears completed
Correct the verb and timing, then verify related orders, referrals, medication records and patient instructions. If another team member may have acted on the incorrect note, notify them through the established escalation path.
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A diagnosis or negative finding is unsupported
Remove the inference, restore the actual symptom or differential and document the evidence that was available. If the unsupported statement entered a signed record, use your organization’s correction or addendum procedure rather than silently altering history.
The note omits a critical fact
Return to the encounter source and chart context, add the fact with its source and time, and check whether the omission affected an order, referral, safety plan or handoff.
The tool repeatedly misunderstands a specialty term or accent
Record the error pattern, increase review for affected visit types and work with the vendor or informatics team on vocabulary, microphone, speaker and template settings. Do not assume a model update fixes the issue without local verification.
The patient declines recording or the system is unavailable
Use the documented non-recording or downtime workflow. The visit must remain fully documented even when the AI feature is not used.
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A policy should assign responsibility, define minimum review steps and make the safe path the easy path. Specify which clinicians may use the tool, approved devices and locations, patient notice and consent language, retention and access rules, incident reporting, downtime procedures and the required sign-off attestation. Include a process for evaluating updates, because a model or integration change can alter error patterns.
Train clinicians with realistic examples: a planned examination rendered as completed, a symptom discussion rendered as a diagnosis, an omitted refusal and a stale copied medication. Measure local edit time and error reports by specialty rather than relying only on vendor claims. Review a sample of signed notes under your quality-improvement process, protect patient confidentiality and use the results to refine templates and training.
Final decision before you sign
Pause if any statement could change diagnosis, treatment, risk, billing, continuity of care or the patient’s understanding of what occurred. Resolve the discrepancy from the encounter and chart, or remove the unsupported statement. Sign only after the note is in the correct record, the required fields and attestations are complete, and the final wording represents your clinical judgment. The technology can draft; accountability for the signed record remains with the clinician.
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