An AI scribe listens to a patient visit and turns the conversation into a draft clinical note. The clinician then reviews, edits and signs that note in the EHR. If a provider says "the scribe app wrote my note," this is the tool they mean.
What is an AI scribe?
An AI scribe is software that captures the audio of a clinical visit, converts the speech to text and generates a draft clinical note for the clinician to review and sign.
The process usually has three steps:
- Capture. The tool records the visit, either through ambient listening during the conversation or through the clinician's dictation afterward.
- Transcribe. Speech-to-text software turns the audio into a transcript.
- Draft. The software turns the transcript into a structured note, such as a SOAP note (Subjective, Objective, Assessment, Plan), and leaves out small talk and repetition.
The draft is not the final record. The clinician remains responsible for the note. They check it for errors and omissions, edit it and sign it in the EHR. The software does not sign anything.
Common synonyms include ambient AI scribe, ambient clinical documentation and AI medical scribe.
In practice at a clinic or small practice
Clinician side. At the start of a visit, the provider opens the scribe app on a phone or computer and starts recording. After the patient leaves, a draft note appears for review. Some clinics ask nurses or medical assistants to confirm during rooming that the patient was told about the recording, for example by asking, "The doctor uses a recording tool for notes. Is that okay with you?" The MA then records the answer wherever the practice tracks it.
Office side. The office manager usually handles the administrative work. That includes vendor setup, user accounts, staff training, getting the BAA signed and writing the patient notice with the privacy officer. Front desk staff may hand out a printed notice at check-in or answer questions such as "Who hears this recording?" or "Can I say no?" Staff should have a short, approved answer to these questions and know who to escalate to.
Not to be confused with
| Term | What it is | How an AI scribe differs |
|---|---|---|
| Human medical scribe | A person, in the room or working remotely, who writes notes for the clinician | An AI scribe is software that produces a draft |
| Medical transcription and dictation | The clinician dictates, and a person or software types it out word for word | An AI scribe summarizes a conversation into a note structure |
| AI assistants in team chat | AI agents in staff messaging tools that work on internal operational threads, such as supply requests or schedule questions | These are not clinical documentation tools and do not write visit notes |
What the rules say
- No legal definition. "AI scribe" is an industry term. No HIPAA or ONC regulation defines it.
- The content is PHI. Visit audio, transcripts and draft notes contain protected health information (PHI), so the HIPAA Privacy and Security Rules apply to how they are created, stored and shared.
- The vendor needs a BAA. An AI scribe vendor that creates, receives, stores or transmits PHI on behalf of a practice is generally a business associate. The practice needs a signed business associate agreement (BAA) with that vendor before any patient audio is recorded. Ask the vendor what the BAA covers, including audio, transcripts, retention, deletion and any subcontractors that process the data.
- Recording consent is mostly a state-law question. Rules on recording conversations come mainly from state law, not HIPAA. Some states require every party to consent before a conversation is recorded. Have the privacy officer or legal counsel confirm the rules for each state where you have a location.
- Other federal rules. Depending on how a tool works, other federal health IT or medical device software rules may also be relevant. Ask the vendor how it classifies its product, and have counsel review the answer.
Related reading
- Protected health information (PHI): what counts as PHI and ePHI
- Business associate agreement (BAA): what the agreement covers and when you need one
- How BAA scope works for software vendors
- More terms in the healthcare operations glossary
Where Chanty fits. chanty.health is published by Chanty, a team chat for clinic staff with a signed BAA from the Business plan. If your team still coordinates in personal group chats, see how HIPAA-compliant staff chat works or start free.