Artificial Intelligence (AI) Scribes in Clinical Care
Artificial intelligence (AI) is advancing quickly and is poised to enhance both health care and its delivery. One notable application is the use of AI scribes, which may help ease registrant burnout and decrease the time devoted to clinical documentation.
Preamble
The College generally supports the use of AI scribe technology, acknowledging its potential to enhance clinical documentation, reduce registrants’ administrative workload, and create more time for direct patient care.
Be aware that Registrants remain responsible for the quality and integrity of their own assessments, documentation and recommendations with or without utilizing AI. For the time being, registrants utilizing AI in clinical practice are advised to proceed with great caution to ensure all Standards of Practice are followed.
What is an AI scribe?
An AI scribe is a technology-driven tool that uses artificial intelligence to automatically document clinical conversations between a registrant and a patient. It captures, summarizes, and in some cases, records the encounter in real time, generating detailed medical notes for the registrant to review.
How is an AI scribe different from dictation software?
While dictation software only transcribes spoken words into text, an AI scribe goes a step further by analyzing the conversation and organizing key information into the appropriate sections of a patient’s medical record. Modern AI scribes can identify and extract clinically relevant details from registrant-patient interactions, generating clear and structured medical notes for the registrant to review.
Responsibilities When Using an AI Scribe
When using an AI scribe, Registrants are expected to:
- Ensure the patient consents to the use of the technology/recording;
- Verify the accuracy of the generated medical records; and
- Take appropriate measures to ensure the AI scribe system is secure and protects patient privacy.
A Registrant’s duty to safeguard personal health information remains the same when using AI scribes as it does in any other context.
AI Scribes in Clinical Care
When using an AI scribe in practice, Registrants must:
- Review all information summarized by the AI scribe for accuracy and completeness;
- Be aware of potential inaccuracies that may be generated by AI scribes; and
- Advise patients about how the AI scribe will be used for the purposes of documentation.
The Canadian Medical Protective Agency (CMPA) makes it clear that artificial intelligence is intended to complement clinical care. It is not a replacement for clinical judgement and assessment. Medical care should always reflect the registrant’s own recommendations based on objective evidence and sound clinical judgement.
When implementing AI scribes, registrants must adhere to the College’s Policy on Charting.
Registrants should also remain aware of their legal responsibilities under the province’s Health Information Act when using AI scribes for documentation support.
Document History
Approval Date: October 9, 2025