AI scribe: consent, review and approval

Consent comes first

The AI scribe is optional for every consultation. Recording only starts after the patient has consented, and the consent is logged with the time, the clinician and the version of the consent wording.

1. 1Explain in plain language that the consultation will be transcribed so that software can draft notes for you to review, and that audio is not kept after transcription.
2. 2Ask whether the patient agrees. They can say no without affecting their care.
3. 3Record their answer in Maatla Care. If they decline, carry on and write notes as usual.

During the consultation

A clear indicator shows while recording is on. You can pause or stop at any time. If the patient changes their mind, stop recording and tell them you have done so.

Reviewing the draft

The draft note is structured in SOAP format. Each item is linked to the part of the transcript it came from, so you can check it quickly.

Items that cannot be traced to the transcript are marked unverified. You must confirm, correct or remove every unverified item before the note can be approved.

Approval and version history

Only the treating clinician can approve the note. Nothing reaches the patient's record until you do. Every edit is kept as a version, so the history of the note is preserved, and later amendments are recorded alongside the original.

Your professional responsibility

You remain responsible for the clinical record. Read the full note before approving it, as you would with notes prepared by a colleague. Transcript text is kept for a limited period after the note is approved or discarded, currently 30 days, and then deleted. The approved note is the record.