Using AI-enabled ambient scribing products in health and care settings guidance for health and care professionals

The adoption of ambient scribes can transform care settings by improving clinical efficiency, enhancing patient care, reducing clinician workload and addressing the challenges of poor data quality. They make certain work tasks easier and allow you to spend more time with your patients and service users.

As a health or care professional, there are several things you need to be aware of to make sure you are working with ambient scribes responsibly.

Before you use an ambient scribe it is important that you familiarise yourself with your organisation’s policies and processes for this type of technology.

You should check:

• whether the AI product you want to use has been approved by your organisation – for example, whether it has been through the organisation's due diligence procedures for technology procurement
• what rules you need to follow when using ambient scribes – to ensure your use of the product is safe and you follow legal requirements and regulatory guidelines

NHS England has produced guidance on adopting ambient scribing products in health and care settings which provides further advice.

If your organisation does not yet have policies or procedures for the use of ambient scribes, you should speak to the relevant people in your organisation about this. This may include your IT, clinical safety or IG team.

You are professionally responsible for any health and care information collected by ambient scribes on your behalf. This is why it is important to only use approved products and use them responsibly.

In some circumstances, you may consider that it is not appropriate to use an ambient scribe, such as during highly sensitive conversations. In these cases, you should use your professional judgement to decide whether or not to use an ambient scribe.

You do not need to ask for explicit consent from patients or service users before using an ambient scribe to perform tasks which deliver individual care. In these cases, it is appropriate to rely on implied consent under the common law duty of confidentiality.

However, as ambient scribes are new, you do need to inform people that you are using them. This is about being transparent and allowing people to dissent (which means you cannot rely on their implied consent), rather than asking for explicit consent (see the sections on being transparent and when someone objects to the use of ambient scribes).

Information about how you use ambient scribes must be made available to patients and service users through your privacy notice (see guidance for IG professionals transparency section for further information).

If you are using ambient scribes for individual care, you must inform patients and service users at the start of any session. This is because ambient scribes are a new technology, and it is not reasonable to assume that people will know they are being used without being informed. We have provided some wording below that may be helpful for explaining an ambient scribe to your patients or service users, which can be adapted according to your local needs.

Although you do not need to ask for people’s explicit consent to use ambient scribes for individual care, people can dissent, in which case you should respect their wishes.

People also have a right to object under the UK General Data Protection Regulation (UK GDPR) and may also exercise this right more formally. You should explain to the patient or service user how their objection might impact the care they receive, for example if there is a risk that this leads to less time to interact with them or that notes will be less structured. You may be able to resolve their concerns. However, if they still wish to make an objection, you should respect their wishes. 

Your health and care organisation may have its own local procedures relating to recording objections and you should familiarise yourself with these.

When you are caring for someone who lacks capacity, you should consider the following when making decisions about using an ambient scribe for their individual care:

• whether someone else has the legal authority to accept or dissent to the use of the ambient scribe on the patient or service user's behalf or has been appointed to represent them
• whether there is any evidence that the patient or service user has previously expressed an objection or preference relating to the use of an ambient scribe, or similar technologies

If there is no evidence of a previous objection or someone who can accept or dissent on their behalf, decisions must be made in the best interest of the patient or service user.

The user of the ambient scribe is responsible and accountable for the accuracy of information which is added to patient or service user records. It is therefore essential that you check the notes which have been produced by the ambient scribe every time it is used, within a timeframe that allows for a meaningful review.

You should consider whether you need to take extra steps to validate the accuracy of an output. For example, if the ambient scribe has translated a consultation from another language, additional checks may be needed by someone who can understand the language and confirm the accuracy of the translation.

Any inaccuracies must be corrected before the information is included in records.

When you use the content produced by an ambient scribe, it is good practice to indicate within the output that it has been produced with the help of an ambient scribe. You can do this by putting this line at the end of the letter or summary, for example:

Where the ambient scribe is not integrated with a clinical system, a suffix can be added to the consultation entry to state that this was produced using AI scribing software, for example:

Where an individual shares information about another person during a consultation, you should consider whether this should be captured in the final output as you usually would when taking manual notes. If it is your professional opinion that this information does not need to be captured in information uploaded to the health and care record, you should remove this when you conduct your review of the output.