Artificial Intelligence (AI) Scribes in Clinical Care
Professional Guidelines Regarding Artificial Intelligence (AI) Scribes in Clinical Care
Preamble
The College supports the use of AI scribe technology, recognizing its potential to support and improve charting, to alleviate physician administrative burden and to allow more time for patient care.
When using AI scribes, registrants are required to comply with the College’s Professional Standards and Guidelines Regarding Charting.
Physicians using AI scribes to assist with documentation should be mindful of existing legal obligations provided for in the province’s Personal Health Information Act.
Standard
When using an AI scribe physician must:
- Ensure the accuracy of medical records;
- Obtain consent to maintain a recording of a patient encounter. Consent is not required to use an AI scribe if no recording is maintained; and
- Take all reasonable steps to ensure the AI scribe is secure and private.
Physicians’ obligation to protect their patients’ personal health information is no different when using AI scribes than in any other circumstance.
Guidelines
When using an AI scribe in practice, physicians should:
- 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 and obtain patient consent before recording conversations using AI scribes.
Definitions
The following definition was provided by the College of Physicians and Surgeons of Alberta’s Advice to the Profession: Artificial Intelligence in Generated Patient Record Content.
Artificial Intelligence (AI): the ability of a digital computer or computer-controlled robot to perform tasks commonly associated with intelligent beings.
Background Information
Artificial intelligence (AI) is being integrated into health care, with the potential to improve and accelerate care.
The use of large language model (LLM) generative artificial intelligence (AI) has exploded since the introduction of ChatGPT (Chat Generative Pre-Trained Transformer) in November 2022. Generative AI tools are being used in the provision of health services, largely in advance of studies to assess their impact on the quality of patient care. Third party tools that generate chart notes from text input or from recorded conversations are rapidly entering the market and being advertised to members.
The impact of LLM generative AI on the quality of health programs and services is rapidly evolving and because of the speed of change, there is currently limited research-based evidence to guide an approach to AI use by regulated members. The College will monitor developments in this field and make every effort to communicate them to members and update this Standard as more information becomes available.
An AI scribe is an AI-powered tool that captures and summarizes (and, in some cases, records) clinical encounters between a physician and a patient into detailed medical notes for the physician’s review in real-time.
AI scribes differ from dictation software. Dictation software converts voice to text. AI scribes extract content from an encounter, summarizing it into text, and applying it to appropriate fields of the patient’s medical record. This technology can analyze and isolate relevant medical information from the conversation between a physician and patient and create a more concise medical note for the physician’s review. Physicians are responsible for ensuring that the AI scribe used is secure and private.
Resources
College of Physicians and Surgeons of Nova Scotia
Canadian Medical Protective Association
- AI Scribes: Answers to frequently asked questions
- Clinical decision-making – Leveraging artificial intelligence
Government of Nova Scotia
Acknowledgements
This standard was informed by the College of Physicians and Surgeons of Ontario’s Advice to the Profession: AI Scribes in Clinical Practice and the College of Physicians and Surgeons of Alberta’s Advice to the Profession: Artificial Intelligence in Generated Patient Record Content.
Document History
Approved by the Executive Committee of the College of Physicians and Surgeons of Nova Scotia: February 27, 2025
Date of next review: 2028