Clinical notes and AI scribes
Who is legally responsible for a note written by an AI scribe?
The practitioner is. An AI scribe produces a draft; the clinical record is created when the practitioner reviews, corrects and signs it. No regulator treats an AI-generated draft as a signed clinical note, which is why review before signing is not a formality.
Written by the HeroMed team · Last reviewed 7 September 2026
What this means operationally
- Never sign unread. The signature is the point at which responsibility attaches.
- Correct rather than tolerate. If the draft phrasing is not what you mean, change it — you are the author.
- Keep the audit trail. Who signed, when, and what changed between draft and signed note.
- Train new staff explicitly. The review step is the first thing to erode when a practice gets busy.
A workable practice policy
- Every note is reviewed and signed by the treating practitioner before the end of the working day.
- Medication names, doses and numbers are checked explicitly every time.
- Consent to record is captured and stored before recording begins.
- A sample of notes is reviewed monthly as a quality check.
In HeroMed the AI Scribe drafts inside the patient record and the note remains a draft until the practitioner signs it.