Get hands-on knowledge to use an AI scribe in alignment with Island Health’s expected use.
- Guidance for Obtaining and Documenting Patient Permission
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When using AI scribe for any patient or client interaction it is important to inform patients and families what an AI scribe is and obtain and document verbal consent/permission. How permission is obtained may vary depending on practical considerations for individual practices.
When speaking with a patient or client to obtain permission, information shared may cover:
- Why AI scribe is being used
- Who may have access to the recording and under what context
- The patient or client right to refuse, withdraw, or adjust permission at any time
- Purpose of AI scribe use
- Potential benefits, limitations and risks of the AI scribe
- Patient decision for use of AI scribe
When documenting permission in the Electronic Health Record, consider creating an Auto Text with standardized content. CMPA recommends including the following:
Examples:
Ambient AI scribe technology was used in this interaction, with patient permission. The scribe output was used to assist in the authoring of this note.
The use of ambient scribe technology was not consented for this interaction, and no generative AI was employed in the production of this note.
Initial permission granted for use of ambient AI scribe technology during this visit was subsequently withdrawn by the patient, at which point the scribe tool was deactivated. No generative AI output has been employed in the production of this note.
- Guidance for Copy & Paste Functionality Using AI Scribe
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Current AI scribes require the use of copy and paste functionality to transfer AI transcribed text into the Electronic Health Record (EHR). To support the successful integration of AI scribe use into your practice, key review points to be aware of have been identified and listed below.
- Verify that the pasted content is for the correct patient and encounter.
- Review and edit each entry to accurately reflect the relevant clinical encounter.
- Be aware of potential biases in AI.
- Develop or use templates in the EHR to preserve structure.
- Check to ensure time-stamps and dates are accurate.
- Ensure pronouns are current and appropriate.
For more information reference Island Health’s Clinical Documentation Policy outlining principles and requirements for documenting a patient’s care to ensure all health records are clinically relevant, accurate, secure and up to date.
- AI Scribe Limitation and Mitigations
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There are associated risks and limitations when using AI scribes. Listed here are common identified risks and limitations of AI scribe use and strategies for mitigation.
Risk Mitigation AI Content Errors
AI may generate inaccurate or fabricated content information not said during the visit. These are known as AI Hallucinations.
Always review the self-authored documentation carefully; compare with your own recall and correct discrepancies before finalizing documentation. AI Contextual Errors
AI may misunderstand clinical context or nuance (e.g., “hypertension” may be misinterpreted as “hypotension”).
Use structured summaries when possible; verify key findings, medical terminology and clinical reasoning before finalizing documentation. Accent and Dialect Recognition
AI may struggle with certain accents, speech patterns, or rapid speech.
Speak clearly and at a moderate pace; rephrase or repeat if the system misinterprets terms. Biases in Training Data
AI outputs may reflect systemic biases present in the data it was trained on.
Stay vigilant for biased or inappropriate language; prioritize inclusive and respectful language in documentation, especially for equity-deserving groups. Continuous Learning and Adaptation Needs
Most AI scribes do not continuously learn from your edits, so recurring errors may persist.
Provide vendor feedback regularly and flag frequent inaccuracies through vendor support channels. Environmental Challenges
Background noise, multiple speakers, or overlapping conversations may interfere with accuracy.
Use in quieter settings, identify who is speaking when needed, and avoid side conversations during recording. Always be mindful of privacy and confidentiality best practices. - Staying Informed: AI Scribe Use in Clinical Practice
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AI continues to change rapidly, and it is important to stay informed. Here are some key reference links and information to support understanding and use of AI scribe in health care.
- College of Physicians and Surgeons of British Columbia
- British Columbia College of Nurses & Midwives
- Island Health Policies
- Standards and Policies
- Key policies from the many that cover information use at Island Health,
- Policy 16.1.3 – Clinical Documentation
- 16.6.2 – Code of Practice Confidential Information Management
- Caring for Your Information Notice
- Canadian Medical Protective Association
- Doctors of BC
- Freedom of Information and Protection of Privacy Act
If you have any questions regarding AI scribe use within Island Health contact clinical documentation HIM.HealthInformationAccess@islandhealth.ca