AI Scribe Usage Policy

1. Purpose and Scope

This policy outlines the procedures and responsibilities for using AI scribe technologies at 360 Med. It is designed to ensure proper patient consent, data protection compliance, and clinical accountability when using these tools.

2. Background

360 Med has implemented AI scribe solutions to reduce administrative burden and enhance the patient experience. These technologies monitor consultations and generate notes to be reviewed and approved by clinicians before integration into patient records.

3. Clinical Responsibility
3.1 Ultimate Responsibility

• Clinicians maintain full and complete responsibility for all documentation entered into patient records.

• The use of AI scribe technology does not transfer or diminish this responsibility in any way.

3.2 Verification Requirements

• Clinicians MUST review the entirety of each AI-generated transcription for accuracy and completeness before saving to the patient record.
• Clinicians must make any necessary corrections or additions to ensure the documentation accurately reflects the consultation.

• The clinician is responsible for ensuring all clinical coding is appropriate and accurate.

3.3 Documentation Procedures

• Currently, clinicians must manually copy and paste the verified transcription into EMIS.

• Future integration may streamline this process, but verification requirements will remain unchanged.

4. Patient Consent
4.1 Explicit Consent Requirement

• Explicit consent MUST be obtained from each patient before using AI scribe technology in a consultation.

• Consent must be clearly documented in the patient record.

4.2 Consent Procedure

Clinicians MUST explicitly ask for consent at the beginning of each consultation before activating the AI scribe. The clinician should briefly explain:

• The purpose of the AI scribe.
• That the clinician will review all transcribed content.
• That the patient has the right to decline without affecting their care.

4.3 Consent Statement

The clinician will take patient consent beforehand and will advise that AI Scribe technology helps document patient conversations in the consultation. This helps clinicians to focus more on the patients instead of taking notes. The clinician will review what was transcribed before it goes into the patient’s record. The patient is completely free to decline the use of AI Scribes.

4.4 Declining Consent

If a patient declines, the clinician must:

• Document the patient’s preference in their record.
• Ensure the AI scribe is not activated.
• Proceed with traditional documentation methods.
• Reassure the patient that their care will not be affected.

5. Data Protection and Security
5.1 Data Processing

• Voice recordings are NOT stored by the AI scribe technology.
• Transcriptions are only retained for 24 hours if not deleted at the end of each session. Clinicians must select under settings for the transcriptions to be deleted after 24 hours.

• Clinicians are advised to delete transcriptions at the end of each session.

5.2 Third-Party Access

• Suppliers can only review consultations if explicit permission is granted by the clinician, typically for troubleshooting purposes.
• Such access must be documented and time-limited.
• Clinicians must lock their screens when stepping away, even momentarily, during AI-assisted consultations.
• AI transcripts awaiting review must be treated with the same confidentiality standards as all medical records.
• Practice staff must not share login credentials for AI scribing systems.

• AI scribe sessions must not be conducted in areas where unauthorised staff or other patients might overhear.

5.3 Training Data Usage

• Data from AI Scribes are anonymised and may be used for training their AI systems.

• Patients should be informed of this distinction if they specifically inquire.

5.4 Compliance

AI Scribe systems operate in compliance with GDPR and have received necessary DPO approvals.

Additionally, we will take all reasonable measures to comply with our legal responsibilities under:

• The Data Protection Act (2018) and UK GDPR.
• The Health and Safety at Work Act (1992).
• The Access to Health Records Act (1990).
• NHS Digital Data Security and Protection Toolkit requirements.

6. Implementation and Training
6.1 Staff Training Requirements

All clinicians using AI scribes must complete training on:

• Proper Consent procedures.
• System operation.
• Verification requirements.
• Data protection considerations.
• Documentation of patient preferences.

6.2 Clinician Acknowledgment

• All clinicians who intend to use AI scribe technology must sign an acknowledgment form provided by the Practice Manager, confirming that they have read, understood, and will adhere to this policy.
• Signed acknowledgments will be maintained on record by the Practice Manager.
• Use of AI scribe technology is only permitted after completion of required training and submission of the signed acknowledgment form.

• All staff must complete annual training on AI usage and data protection.

7. Incident Reporting
7.1 Reporting Procedure

• Any concerns about data protection, accuracy, or consent issues must be reported immediately to the Digital Lead and Practice Manager.

• Technical issues should be documented and reported to IT support.

8. Policy Review

This policy will be reviewed annually or when significant changes to the technology or regulations occur.

9. Appendices

Appendix A: Quick Reference Guide

• Obtain and document explicit patient consent.
• Use the AI scribe during consultation.
• Review the entire transcription for accuracy.
• Make necessary corrections.

• Copy verified content into EMIS.

• Delete the transcription after use (recommended) or within 24 hours.

Appendix B: Patient Information

• Reference to the patient-facing information sheet about AI scribe services.

10. Policy Status

Policy Version: 1.0
Approved By: 360 Med
Date: 2nd September 2025
Next Review Date: 2nd September 2026