Can you use AI for medical notes?

Clinicians may wonder: “Can you use AI for medical notes?” This article has all the information you need to make an informed decision for your clinic or private practice.

Many therapists in private practice try to make their administrative work more efficient. And, in an effort to achieve that increased efficiency, many practices are using artificial intelligence (more commonly referred to as AI).

So, to answer: “Can you use AI for medical notes?” Yes, AI can be used to assist in creating medical notes.

In fact, there are a number of applications for AI in medical and therapeutic practices—including AI for clinical notes and medical notes.

Many therapists now use clinical notes AI tools such as Note Taker, an AI note software for mental health clinicians that can help to create progress notes, including DAP, BIRP, and SOAP notes.

But how, exactly, do you choose which software to use? Which features should you be looking for?

Let’s take a look at how to use AI in medicine—and how the right notes software  can not only help you streamline your medical note process, but actually help improve patient care.

What are clinical notes AI tools?

Clinical notes AI tools are software that leverages AI to support users in note taking and management.

SimplePractice’s AI-powered digital Note Taker can help streamline the process of clinical documentation.

While functionality can vary, the best AI documentation tools offer a few key features that you should look for, including:

Real-time transcription

Clinical notes AI software can transcribe conversations live, in real-time—which allows clinicians to focus on their patient instead of trying to write everything down.

Speaker differentiation

While live transcription is a solid feature, it’s not going to be super helpful if it’s unclear who said what. The right AI clinical notes software  offers speaker differentiation—which allows you to easily separate your part of the conversation from your patient’s.

Summaries and recommendations

The best AI documentation tools can analyze and provide information on each individual note—for example, a summary of the visit, a list of action items for the patient, or items that need a follow-up.

Multi-device functionality

If you use mobile devices or tablets in your practice, it’s important to choose a software that offers multi-device functionality. That way, you can easily capture or access your notes from whatever device you’re using.

Security

Protecting client information is important for all industries. But in the medical and therapy field, it’s not just important—it’s required.

When choosing an AI notes tool, make sure you choose a software that’s compliant with any laws and regulations that are relevant to your practice (like HIPAA).

When using AI for medical notes, it’s important to look for a note software specifically created for mental health and medical purposes, which can offer more targeted features (like HIPAA-compliance or therapy notes templates).

“Many AI tools offer features…tailored to therapy notes, which streamline the process,” says Kristie Tse, LMHC, licensed psychotherapist and founder of NYC-based Uncover Mental Health Counseling.

The pros and cons of using clinical notes AI tools  

Now that you know the answer to “Can you use AI for medical notes?,” perhaps the question on your mind is “Should I use AI for clinical notes?”

Using AI for medical notes can offer some serious benefits—for you, your practice, and your clients or patients.

Some of the benefits of AI notes software  include:

• Increased efficiency. AI makes the process of creating medical notes faster, more effective, and less attention-intensive—which can free up your time and energy to focus on your patients. “Using AI for medical notes can significantly improve efficiency in a practice by reducing the time spent on documentation, allowing clinicians to focus more on patient care,” says Tse.
• Less human error. AI can reduce human error—and make your notes more accurate and comprehensive. “AI software reduces human error, ensuring critical details are captured consistently,” says therapist Rebecka Parker, LCSW.
• Easier note management. AI software can also make it easier to access and manage notes; instead of paper files, which are hard to keep tidy and tedious to work through, AI notes software keeps patient notes organized and easily accessible—which can help save serious time and improve patient experience. “AI software enables quick retrieval of patient information, improving continuity of care,” says Parker.
• Templates. Most types of  AI clinical notes software  comes equipped with pre-designed templates for medical and therapy notes. This “maintains uniformity across records—which is]essential for compliance and insurance claims,” says Parker.

But there are also some potential downsides to using clinical notes AI tools, including:

• Learning curve. Like any new software, these clinical notes AI tools come with a learning curve—and if you (or your team) aren’t the most tech savvy, that curve might feel steep.
• Need for human read-through and validation. AI comes with some error potential. For example, “AI may struggle with nuanced language, such as patient emotions or unique phrasing,” says Parker—which can make the notes hard to read or understand.
• Security issues. When it comes to AI notes software, not all tools are created equal. More specifically, some are more secure than others—which can lead to issues with patient information. “If not properly managed, sensitive data could be at risk,” says Parker.

Best practices for using AI for medical notes in your practice

When considering the question “Can you use AI for medical notes?” and moving forward with implementation, there are a few best practices you’ll want to keep in mind—both when choosing a software and when using AI for medical notes.

Make sure to:

Read reviews

The notes software you choose will determine how successful (or unsuccessful) your experience of using AI for medical notes ultimately is—which is why it’s important to do your research and read reviews (ideally from other clinicians).

“Look for AI tools vetted by healthcare professionals with strong user reviews,” says Tse.

Prioritize security

As a clinician, you are dealing with extremely sensitive patient information—information that’s protected under HIPAA. As such, make sure that whatever tool you use offers the highest level of security and compliance.

“Security should always be a top priority by using encrypted, reputable platforms,” says Tse. “It’s crucial to ensure these tools comply with HIPAA and other privacy laws to protect sensitive client information.”

Start slow

As mentioned, AI software can have a bit of a learning curve. And if you go all-in on day one—before you and/or your team is comfortable with how to use the software—mistakes are more likely, which can actually cause more work.

Instead, “to incorporate AI into practice, start small by integrating it into non-critical workflows and gradually expand as you gain confidence,” says Tse.

Add a human touch

While AI notes software can be helpful in streamlining the medical notes process, you shouldn’t rely on it completely.

“Always review and personalize notes to maintain authenticity and uphold the therapeutic relationship,” says Tse. “Balancing technology with human connection is essential to keep the essence of psychotherapy intact.”

Hopefully this article has helped to provide a comprehensive answer to the question “Can you use AI for medical notes?”

How SimplePractice streamlines running your practice

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If you’ve been considering switching to an EHR system, SimplePractice empowers you to run a fully paperless practice—so you get more time for the things that matter most to you.

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