An AI scribe listens to a visit and drafts the note. It can give clinicians back real time. It also records patients, so you need a plain answer on consent and a short list of questions for any vendor.
This guide is written for independent practices in Medina and across Northeast Ohio, and applies to practices anywhere. It is general information, not legal advice.
It depends on which rule you are asking about. Three different things are in play.
HIPAA generally allows using patient information for treatment, payment and operations, including through a vendor that has signed a business associate agreement. The vendor needs that BAA before it touches patient information.
Ohio is a one-party consent state, so a participant can record. Some other states, such as California, Florida, Illinois, Pennsylvania and Washington, require everyone's consent. If a telehealth patient is in one of those states, their state's rule may apply.
Even when no law requires it, patients trust a practice that says what it is doing. Note in the chart that the patient was told, and make it easy to say no.
Psychotherapy notes and session audio call for extra care, and substance use treatment records may fall under 42 CFR Part 2. Ask the vendor how each is handled, and whether the scribe can be turned off for certain visits.
"We use an AI tool that listens to our visit and drafts my notes. I review everything it writes. If you would rather I not use it today, just tell me."
Ask in writing, and keep the answers. A good vendor answers these easily. A vague answer tells you something too.
Ask for the signed document, and ask whether free trials are covered.
Many scribes run on another company's AI. Ask who the subprocessors are and whether each is under the BAA.
Ask where the answer is written in the contract, and whether you can opt out in writing.
Audio, transcripts and drafts. Ask whether you can set retention to zero, and what you lose if you do.
And under what rules.
A true two-way connection, or copy and paste? Does it ever overwrite what is already in the chart?
And does it hold up when the patient is in another state?
A badge is not a report. Ask how often drafts leave things out or get things wrong, measured on notes like yours.
How it is deleted, how fast, and whether they will confirm in writing.
"HIPAA-friendly" or "HIPAA-aligned" with no BAA
A BAA only on a plan the vendor will not name
Patient information allowed only if a user turns off a setting
A free or personal account being used for work
No list of subprocessors, or no answer on who the AI company is
Price hidden until after you sign
An AI scribe drafts. The clinician who signs the note is responsible for it, so every draft needs a real review before it enters the chart. Professional guidance, including from the APTA and the AMA, points the same way. A scribe can leave things out or get things wrong, which is why reviewing matters more than the technology.
Looking at AI for your type of practice? See physical therapy, primary care, behavioral health, chiropractic, dental, and health and wellness.
Not by itself. HIPAA generally lets a practice use patient information for treatment, payment and operations, including through a vendor that has signed a business associate agreement (BAA). But other rules can still require consent, such as recording laws and some state AI rules, and telling patients is good practice either way.
Ohio is a one-party consent state: a person may record a conversation they are part of, or that one participant agrees to. That helps for in-person Ohio visits. If the patient is in another state, which is common with telehealth, that state's law may require everyone's consent. California, Florida, Illinois, Pennsylvania and Washington are examples. The simplest habit is to tell every patient and document it.
The clinician who signs it. An AI scribe drafts, and the clinician reviews and corrects before the note enters the record. Professional bodies, including the APTA and the AMA, have said the same in their guidance on AI.
Some do, with extra care. Ask how the tool treats psychotherapy notes and session audio, whether it can be turned off for certain visit types, and whether substance use treatment records covered by 42 CFR Part 2 are handled under that rule. Many practices start with administrative work and revisit documentation later.
Keep it short, plain and optional. For example: "We use an AI tool that listens to our visit and drafts my notes. I review everything it writes. If you would rather I not use it today, just tell me." Document that the patient was told. This is a sample, not legal advice. Adjust it to fit your practice.
We look at how your practice works, what tools make sense, and what to ask before you sign. We do not sell software. Most conversations start with a free 15-minute call. Please do not share patient information on the call.