At your next UCSF Health visit, your provider may ask your permission to take medical notes with the assistance of a new tool called an AI scribe. AI scribe technology uses artificial intelligence to draft detailed medical notes based on the conversation you have with your doctor. This allows your provider to give you their undivided attention during your visit – focused on listening to you and providing you with the best possible care.
AI Note-Taking at Your UCSF Health Visits
Medical note-taking
Taking notes to summarize your visit helps track your health and guide your care. These notes, stored in your medical record, include details like symptoms, medications, and treatment plans, helping you and your providers make informed decisions.
During a medical visit, you may have noticed your provider typing notes while listening to you, which can be challenging. Traditionally, clinicians have made their own notes (typed, written, or spoken and transcribed) or relied on notes taken for them by a human scribe. But recently, AI has been brought in to help.
At certain appointments, UCSF Health providers now use an AI scribe to capture details about your medical history, treatment plans, and other relevant information during your medical visit.
How AI note-taking works
With your consent, a secure tool records conversations between you and your provider at each appointment and starts a draft note. Your provider then receives a detailed write-up of what happened at your visit and what was discussed. Your provider reviews and edits the AI-generated draft before finalizing it in your medical record, ensuring all the information is accurate and complete.
After your appointment, you will receive an After Visit Summary, which will include instructions for any medications, referrals, tests, home care or other important follow-up steps. Your After Visit Summary may be provided in your MyChart account or printed out at the time of check-out.
FAQ:
Who has access to the notes in my file?
Notes taken during your health visit, whether taken by a human or AI scribe, are protected by federal and state privacy laws. Only your care team and authorized personnel at UCSF have access to those notes.
Where is my data stored?
UCSF Health relies on industry leaders in medical data storage that comply with the Health Insurance Portability and Accountability Act (HIPAA). Data encryption, and other best practices for privacy, keep your health information secure. AI scribe recordings are only used for drafting the notes – not for modeling or research. Data is permanently deleted within 60 days after ensuring high-quality notes.
Can I opt out of AI note-taking?
Yes. At the start of your visit, your provider will ask your permission to use an AI scribe to record and summarize what goes on. If you prefer them not to use this method, just let them know you prefer not to be recorded. Also, if you don't want certain parts of the conversation recorded, you can ask your provider to pause the AI tool. Your clinician wants you to feel comfortable during the visit.
If some of my health information in the AI notes is not correct, what should I do?
Review your After Visit Summary very carefully and ask your provider to correct any inaccurate information at your next visit. Your health information is reviewed and updated in your electronic record each visit. If you feel the information needs to be changed before your next visit, you may message your provider in UCSF MyChart or call your provider's office.
How do I know UCSF's use of AI is trustworthy?
UCSF is committed to ensuring AI is used safely and responsibly, prioritizing patient safety, data privacy, and clinical excellence by upholding the principles of trustworthy AI in health care and research. We follow Trustworthy AI guidelines created by the US Department of Health and Human Services in 2021, to ensure that health-related AI is implemented in a way that is ethical, effective and secure.
