If you choose to use Voice to Chart to assist with clinical documentation, you should consider updating key legal documents to reflect this process. In particular, practices may want to review and revise the following:
- Patient Consent for Treatment and Examination
- Consent to Treat a Minor
- Patient Privacy Policy
See below for sample verbiage that you can consider adding to your existing or new policies.
See below for example considerations you can make to your existing policies
Disclaimer: ChiroUp provides the following examples solely for consideration when drafting or updating these policies to address AI-assisted documentation and visit recordings. ChiroUp does not provide legal advice. Laws and regulations governing documentation, privacy, and healthcare practices vary by jurisdiction and are subject to change. It is the sole responsibility of each provider to ensure that their documentation, policies, and procedures comply with all applicable federal, state, and local laws and regulations. Any sample language or guidance provided by ChiroUp is for informational purposes only and should be treated as general examples to consider when drafting such policies. Providers are encouraged to consult with qualified legal counsel to ensure compliance with all legal requirements specific to their practice.
Consideration For Consent To Treatment & Examination - Addendum For Visit Recording
As part of our documentation process, your provider may use secure audio recording and transcription tools during your visit. These recordings are processed using artificial intelligence to generate a written summary, which becomes part of your official medical record. Audio recordings are not retained as part of the official medical record. By signing this agreement, you consent to this recording and documentation process. If you prefer not to have your visit recorded, you may opt out by submitting a written request to our office. Note, however, that if you opt out of future recordings after consenting, the prior consent will not be affected by the opt-out. Your care will not be affected if you choose to opt out.
Consideration For Consent To Treat A Minor- Addendum For A Combined Consent Document (That Already Includes The Language Above)
As the legal parent/guardian, I consent to the use of automated documentation tools during the minor’s visit(s), including the creation of audio recordings, transcripts, and visit summaries.
Consideration For Consent To Treat A Minor- Addendum For A Stand-Alone Document
As part of our documentation process, the provider may use secure audio recording and transcription tools during the minor’s visit(s). These recordings are processed using artificial intelligence to generate a written summary, which becomes part of the minor’s official medical record. Audio recordings are not retained as part of the medical record, subject to applicable law.
By signing this authorization, I, as the legal parent or guardian, consent to the use of these automated documentation tools during the minor’s visit(s), including the creation of audio recordings, transcripts, and visit summaries. I understand that I may opt out of future recordings at any time by submitting a written request to the office. I acknowledge that opting out will not affect any recordings made prior to the request and that the minor’s care will not be impacted by this decision.
Consideration for Privacy Policy Update Regarding AI-Assisted Documentation and Recordings
In certain cases, your provider may use secure audio recording and transcription tools during your visits to assist with clinical documentation. These recordings are processed using encrypted, HIPAA-compliant services, including artificial intelligence, to create a written summary for your medical record. Audio recordings and transcripts are not retained as part of the official medical record. These tools are used solely to support accurate and efficient documentation of your care.
Related resources
Sample Authorization Form: Patient Authorization for Audio Recording, Transcription, AI Documentation, and Temporary Storage
Sample Consent to Treat form: Consent to Chiropractic Treatment (includes visit recording )
➤ The linked forms are sample forms only. It is not required by ChiroUp that you use these forms - they are simply available for reference and guidance as you consider your own office policies. It is the clinic's responsibility to ensure that their documentation, policies, and procedures comply with all applicable federal, state, and local laws and regulations.