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AI Scribe

AI Scribe listens to a consultation and turns it into a draft clinical note. The clinician stays the author: the Scribe proposes, and a person reviews, corrects and signs. A note is never filed on the Scribe's own authority.

This guide covers how to use it. For what the Scribe is built to do at a fertility clinic (consults, monitoring visits, calls and referrals) and the questions clinics ask before turning it on, see the AI medical scribe for fertility clinics overview on fertiligent.ai.

Controlled rollout

AI Scribe is off by default. It is switched on per clinic, deliberately, after the privacy assessment that handling consultation audio requires, never as part of a release. Ask your Fertiligent contact whether it is enabled for yours.

What a visit looks like​

A visit can also be recorded before the patient is identified, a walk-in, or a room already under way. Start from the Scribe area or the chart, and attach the patient afterwards; the note cannot be signed until they are attached, so an unattached recording can never become part of someone's record by accident.

  1. Say what the visit will be. Starting a recording, from the chart or as a walk-in, shows the kind of visit and the note template your clinic has assigned to it as two chips; either can be changed before recording. The patient search lists the clinician's recent patients before anything is typed, and searches as you type.
  2. Consent, before anything is recorded. You read the consent statement to the patient and record their agreement. The dialog is short (the script, who is in the room, the agreement), keeps keyboard focus inside it until you finish, and closes with Escape. Recording can start once the consent wording has loaded. There is no separate microphone test: once you start, the recording indicator shows a live level ring, and if the microphone hears nothing for ten seconds the dock says so and offers the device picker.
  3. Record. The recording can be paused, given written context you type in, and set to the language actually being spoken; the note shows that language afterwards, with the visit date. While it runs, a live checklist shows what this kind of visit should cover, the measurements and the talking points, so what is still missing is visible while the patient is still in the room. Pressing Stop lists anything not covered yet before you finish. The checklist states each item in words and shape, not colour alone.
  4. Confirm who spoke. The Scribe separates the voices it heard. When it can match them with confidence, the Recording stopped dialog states the match (Speakers matched: Speaker-1, Clinician; Speaker-2, Patient), asks nothing, and the note starts at once; a Wrong? link on the note swaps them. Otherwise it asks you to say which is which. The transcript and every cited line then carry the role, not the recorder's speaker labels, and the clinic's voice is named after the person who recorded (Ada Okafor (Clinician)). A nurse's recording, meaning a nurse teaching visit or any visit recorded by a staff member whose role is Nurse, is captioned Nurse rather than Clinician, and the note says "the nurse" and "Nurse to".
  5. Review the draft note, correct it, and sign it.

While the note is on its way​

Pressing Review now after Stop opens the note screen before the note exists. It shows where the work is (Recording saved, Transcribing the voices, Matching the speakers, Writing and checking the note), how long ago you stopped, and that transcribing usually takes up to four minutes and the note a couple more. The transcript appears as soon as it is ready, so the wait can be spent checking who said what. You can leave: the work carries on and the note appears in the review queue. If the note arrives while you are reading another tab, the screen says Your note is ready rather than switching tabs under you.

Where your clinic has turned it on (off by default), consent is recorded once per patient rather than per visit. A returning patient who has already consented starts a recording straight from their chart (one line per consented person, with Withdraw beside it) and you reconfirm aloud, which the transcript captures. Someone new in the room is added through the same short dialog.

The consent statement a patient agrees to is recorded by version, and the retention promise is read back from that version when the audio's deletion date is set. The wording the patient heard is therefore the wording the system enforces. It cannot promise one thing aloud and keep the recording under another.

If the system does not recognise the consent wording it was given, it refuses the capture rather than guessing at a retention period nobody promised.

The speaker check is a safety gate, not a formality​

A recording that heard fewer voices than the room held cannot be confirmed. Before this check existed, such a recording attributed a patient's words to the clinician, which produces a note that reads as clinical assessment when it is the patient speaking.

A patient on a call​

Controlled rollout

Call audio is off by default and turned on per clinic. Ask your Fertiligent contact whether it is enabled for yours.

Some visits happen with the patient on the phone or a video call. If the clinician is on speakerphone, the microphone hears the patient and the recording needs nothing special. With a headset it does not: the patient's voice arrives in the earpiece and never reaches a microphone, so only the clinician would be recorded.

Call audio takes the call as a second channel beside the microphone, so the note is written from both sides of the conversation. Where it is on, a Call audio control sits beside Start recording on the chart, with three ways to connect the call:

  • A browser tab. Share the tab the call is in and turn on sharing its audio in the browser's prompt. Prefer this one: it captures that tab and nothing else.
  • This whole screen. Share the screen with the computer's audio turned on. This works on Windows and ChromeOS only; on a Mac the browser cannot capture the computer's sound at all, so the option is shown unavailable there. It captures everything the computer plays, other calls and notifications included, so tell the patient what is being captured.
  • An audio input. A second input device that carries the call: a virtual audio device, a telephony handset or a room system. This is the route on a Mac for a desktop calling application. An ordinary microphone is not one, and the screen will not accept the microphone the recording itself is using.

Which of these a clinician is offered depends on the browser and the computer. The ones that cannot work are shown with the reason on them rather than hidden. Sharing a single window never carries audio, so if a window is shared the screen says so and asks for the tab instead.

The call is connected before the recording starts; it cannot be added to a recording already under way. Once connected, a level reading shows the call is live, so a wrong tab or a muted call is found before the consultation rather than at signing. If the call audio stops part way through (the share is stopped, the tab is closed, a device is unplugged), the recording carries on with the microphone alone and the dock says at once that the person on the call is no longer being recorded. Nothing before that point is lost. To record the rest of the call, stop and start again with the call connected, or switch to speakerphone.

Each side of the call is transcribed separately, so who said what comes from the recording itself rather than from telling voices apart, and the record says the visit was recorded from a call.

A patient on a call cannot see the room and may not know who else is there. When call audio is connected, the consent dialog names the patient as on the call and What to say holds a script written for the phone or a video call. It asks whether anyone with the patient can hear (they would be recorded too, and need to agree) and ends by asking the patient whether they are OK with it, so wait for a spoken yes. Anyone else who can be heard is added with Add someone else, as in the room, and the dialog reminds you to tell the patient who else can hear.

A clinician on speakerphone can tick The patient is on a call (phone or video) to get the same script. It starts unticked on every visit. The consent is recorded as given on a call, so each visit's record shows how consent was asked.

The call wording is a draft for your clinic's own review, like every consent wording in the product. Rules about recording a call differ from place to place.

The note​

The template is proposed after the recording, from what was actually said, rather than fixed in advance by the appointment type. A consultation that turns into something else gets a note shaped like the visit that happened.

  • Your clinic writes its own templates, on screen, and which kind of visit each applies to, including donor sperm, donor egg, surrogacy and embryo adoption. A template is one plain-text document: a plain line is a heading, [square brackets] say what to write there from the visit, (round brackets) are instructions to the scribe, and "quoted text" is written exactly as given. A template written elsewhere in that form pastes in unchanged, and a template can be created from an example note. A template that says what the visit should cover also drives the live checklist: its headings are the talking points.
  • Editing a template makes a new version rather than overwriting the old one, so a note written months ago still shows the wording it was written against. The templates page shows which kinds of visit a template is assigned to and, separately, when a note was last written with it, and who wrote it. In the editor, sections and talking points are reordered with small arrow buttons, a removed section can be brought back with Undo, and leaving with unsaved changes asks first.
  • A template can be marked Use for a document, not a visit note, for a follow-up email or a letter written beside the note. It carries a Document mark on the templates page and is never offered for a visit note; see Documents from the session.
  • A draft can be rewritten against a different template and level of detail without recording the visit again.
  • It can be copied out for a record system that is not this one. The button copies what is on screen and says which: Copy the note, or on the Transcript tab Copy the transcript, which is headed as a transcript rather than a clinical note and has one line per utterance with its speaker.
  • A signed note can be added to with an addendum, without unsigning it.

Reading and editing the note​

Each section is a paragraph of prose. A sentence that needs checking carries a small mark at its end, with the reason on hover. Selecting a sentence shows its evidence in a column beside the note: the transcript lines it rests on, each with a line of context before and after, the quoted words marked, and the speaker named. On a narrower screen the evidence appears under the paragraph instead. Nothing covers the rest of the note, so a sentence can be read against its neighbours and its source at once.

Where a check found something, the evidence says what in plain words (Nobody said this, A number here isn't in the line it cites) and offers Edit, Remove and Ask about this; a sentence that passed offers Edit. With a sentence selected, the up and down arrow keys move through the note in reading order, and Escape clears the selection.

The transcript tab marks what the conversation said that the note does not reflect. Every line the note does not cite is read against the note, so small talk, acknowledgements and things the note says in other words are not counted: the number at the top is what the note genuinely left out (1 line not reflected), not every line without a citation. A note written before this check existed shows the plain count instead, and says that no second reading was made.

You edit by clicking into the note and typing, as in any text editor; a correction can also be dictated. Changes are saved when you leave the section. A sentence you wrote yourself is marked with a small hollow dot and is never flagged; what you left alone keeps its link to the transcript.

The note screen holds only the note. Speakers, transcript, context and earlier drafts each have their own tab, and Ask about this session is a single line at the foot of the page whose answers open as tabs beside the note.

Documents from the session​

From that line you can ask for documents written from the visit: a letter to the patient, a referral letter, a letter to the family physician, a work-up letter, a consent discussion, a summary. Quick asks for the common ones (a copy for the patient, a referral letter, a letter to the family physician, a summary for the chart) fill in the request for you to edit before sending it.

Your clinic's document templates appear on the Documents tab under Or write from a clinic template:. Picking one sends nothing on its own: leave the request blank, or add anything extra, then send. The document follows the template and nothing more. It adds no heading, paragraph or summary the template doesn't ask for, and its "quoted text" is written exactly as given. A line asking for something the visit never mentioned is dropped. The patient's or clinician's own name stays in its brackets for you to fill.

Documents can be written after the note is signed: the Documents tab stays open, and the signed note itself stays locked.

Each document is written in a chosen language, and any document can be rewritten in another language from its own tab; the chosen language wins even if the original request named a different one. A document keeps its paragraphs, lists and headings on screen and when pasted elsewhere. Like the note, a document is checked against the transcript and is yours to review before it goes anywhere.

A document can be copied straight from its tab, and closed from it when it is not wanted. Closing removes it from the list but keeps it for audit, a document that was written is never silently gone.

Measurements carry their source​

Measurements taken during the consultation appear on the note, each with the transcript lines it came from, and the transcript's line numbers are shown so a citation points at a line you can actually find. On a wide screen they sit beside the note, and say so when the note has been edited since they were read from it.

A note that recorded no measurements stays silent rather than printing empty rows, because "not measured" and "we do not know" are different claims, and only one of them is safe to put in a chart.

The Scribe reports transcript confidence alongside the note, so a difficult recording is visible as one rather than inferred from a poor result.

What review opens for you​

Reviewing a draft, the note opens the statements worth a second look and leaves the rest collapsed. What gets raised is what a check disputed, not every sentence that happens to carry a measurement or a citation.

That distinction matters: a review screen that flags almost everything gives a clinician nothing to act on, because there is no signal in it. If a statement is open, something about it did not stand up.

Follow-up actions​

The follow-up actions in a signed note are captured with the lines they came from, and become work a clinician accepts or dismisses. Nothing is actioned because the Scribe heard it, and accepting an action does not book or send anything by itself.

Each action says who is to do it (the patient, the clinician, the clinic, or the couple) and when the room said it should happen, in the room's words. The same action said twice is listed once. An action to arrange something that is already booked for the patient says so, so nobody books it twice.

A decision can be changed: Change this returns an accepted or dismissed action to undecided. The record keeps who had decided and when, and who changed it; nothing is erased.

The review queue​

The queue lists the notes waiting for review. A remark that applies to most of them, such as that the speakers were matched automatically, is said once above the list rather than under every row.

What happens to the recording​

Audio is deleted on the schedule the patient consented to, and the default is to purge it as soon as the note exists. Retention is enforced by the system, not by whoever remembers.

Discard is available during and after a capture, for the wrong patient, or a recording that should not exist. Discarding only ever brings the deletion forward: it destroys a recording, it can never extend one. That is why it sits with the clinician in the room rather than with an administrator.

A recording abandoned without being finished is closed out on its own, and without extending how long it is kept. A tab closed in the few seconds after Stop does not lose the consultation: the recording is finished on its own a few minutes later and the note follows as usual. A tab that is recording is never refreshed onto a newly released version.

A recording interrupted before it was stopped (a crashed browser, a computer that shut down) is offered on the patient's chart with Recover it. Recovering saves what was recorded, finishes the recording and writes the note, which appears in the review queue as usual; the last few seconds may be missing. Recover it on the computer that recorded it. If the recording is still open in another tab of that browser, even paused, the chart says so and offers nothing to recover: stop it in that tab and the note is written.

In the patient chart's Scribe tab, recordings that were discarded, failed, or were never started are folded away, so the list shows the sessions that carry a note. A recording that holds no audio can be removed from the chart outright. The chart card names the kind of visit on a chip beside Start recording and remembers the last choice, and the note page names the patient the way the chart does and links back to it.

Who can do what​

Access is granted by role, see roles and permissions.

CapabilityWho has it by default
View encounters, record, discardClinical staff
View, generate and edit the draft noteClinical staff
Sign a noteNot clinical staff by default: granted deliberately

Signing is held back on purpose. Recording a consultation and attesting to a clinical note are different acts, and the second is granted to the people your clinic decides may make it.

Every AI Scribe permission is additionally gated on the feature being enabled for your clinic, so granting a role does nothing until the feature is on.

Billing codes (controlled rollout)​

Beside a signed note, the Scribe can list suggested billing codes with the documentation each one needs, and say plainly when no code on the list is supported by the note, or when the coding check did not answer. A code is a draft until a reviewer ticks it; viewing and reviewing codes are separate permissions. It is off by default and turned on per clinic, while its accuracy continues to be measured; ask your Fertiligent contact.

Before you turn it on​

AI Scribe records patients. In Ontario, an AI tool handling personal health information is expected to have a privacy impact assessment completed before use, and to keep a human in the loop for anything that reaches the record. This product is built for the second, the clinician reviews and signs every note, but the first is your clinic's to do.

Talk to your administrator about:

  • the consent wording your clinic will use, and the retention period it promises, including the wording for a patient on a call if call audio will be turned on;
  • who may sign, as distinct from who may record;
  • how a wrong-patient recording gets discarded, and by whom.