About the toolkit
This toolkit covers patient consent for an AI scribe used for transcription only, meaning a tool that listens to the visit and drafts a note that the physician reviews. It does not cover non-transcription functions of AI scribes.
The toolkit applies only to community-based physicians governed by BC’s Personal Information Protection Act (PIPA). It does not apply to physicians working in the public sector, such as health authorities governed by the Freedom of Information and Protection of Privacy Act (FIPPA).
Foundations and templates
Consent foundations
These foundations form the basis of valid AI scribe consent. They help establish trust between the patient and clinic and protect both if that trust is ever questioned. Each element below must be met for consent to be valid.
| Element | Requirement |
|---|---|
| Express | Consent must be express (actively given), not implied or bundled into general technology consent. Verbal or clearly written consent is acceptable. |
| Informed | The patient receives information in plain language about what the scribe is, what it records, how the information is used, and privacy and accuracy considerations. |
| Before recording | Consent is obtained before the scribe is turned on. |
| Patient’s right | The patient is free to decline the use of an AI scribe, and care is expected to be unaffected by this choice. |
| Who must provide consent | All persons in the room or within the recording area whose personal information may be captured should be considered before the scribe is activated including caregivers, translators, other patients, or staff. Consent must be collected if their personal information will be captured by the AI scribe. |
| Withdrawable | The patient may withdraw consent at any time without it affecting their care. |
Written consent form template
The reasonable person test
Consent does not remove the clinic’s responsibility to ensure that the collection, use, and disclosure of personal information through an AI scribe are for purposes a reasonable person would consider appropriate in the circumstances. Only information reasonably necessary for those purposes should be collected.
Consent form template
Before using this template, confirm with your vendor how your AI scribe collects, uses, discloses, stores, and processes patient information, including any secondary uses. Adapt this consent form so that it accurately reflects the tool used by your clinic.
Download the AI scribe patient consent form template.
Verbal consent script
This script can be used for both initial and ongoing visits.
Before turning on the AI scribe, the health care provider will say:
“I use an AI scribe to help me take notes during our visit. An AI scribe is a technology that listens to our conversation in real time and drafts a summarized note that I will review and edit afterward. It doesn’t make any decisions about your care. Like other digital tools, there are privacy risks, and the note may contain inaccuracies or bias, so I review it for accuracy and completeness before it goes into your medical record. You can decline or withdraw your consent at any time, and your care won’t be affected. Do you have any questions before I turn on the AI scribe?”
Answer any questions. If the patient asks for more detail, provide other resources such as the Canada Health Infoway’s AI scribe patient poster.
Note: Once the patient has consented, turn on the AI scribe and confirm consent within the tool, if prompted. The EMR should remain the primary record of the patient’s consent status.
Documenting and confirming consent
Documenting consent in the EMR
Minimum documentation stamp (verbal consent)
“Patient provided verbal consent to use an AI scribe. Nature and purpose of use, including relevant privacy and accuracy considerations, explained; patient advised they may decline or withdraw consent at any time without affecting their care.”
If a written form was signed
“Signed AI scribe consent form on file, dated [date].”
Where consent can live in the EMR (adapt to your EMR)
- A flag or custom field on the patient chart recording consent status and date, so that the information is accessible to other providers or authorized individuals for reference.
- A note stamp at the top of the AI-drafted visit narrative.
- A scanned form in the documents section, if written consent is used.
For providers with access to the Practice Support Program (PSP), Health Technology (HT) coaches can support you in developing a workflow tailored to your practice, based on the options available in the EMR. For HT coach support, please submit a service request.
Confirming consent
Before each visit
- First time with a patient: Confirm the patient has reviewed or signed the consent form or has had a discussion with the health care provider and has given verbal consent. If not, do not turn on the scribe.
- Subsequent visit (optional): Give a brief verbal reminder that the scribe is in use before turning it on.
If the patient declines or has withdrawn consent, do not activate the AI scribe.
Handling consent decisions
Decline and withdrawal scenarios
In each scenario below, the same principle applies: care is not affected by the patient’s choice.
Patient declines at the start of the visit
- Do not turn on the scribe.
- Revert to your usual or alternate documentation for that visit.
- No further action needed. You may ask again at a future visit.
EMR note: “Patient declined AI scribe use; manual documentation used.”
Patient withdraws consent mid-visit
- Stop the scribe immediately when asked.
- Follow your clinic and vendor process for stopping the session and handling any audio, transcript or draft already created.
- Do not assume that withdrawal automatically permits deletion of already gathered information except at patient request. If requested, delete the partial recording or draft for that visit; otherwise, ensure the partial draft is reviewed before transfer to the EMR.
- Continue the visit with an alternate or manual documentation method.
EMR note: “Patient withdrew consent to AI scribe partway through visit; scribe stopped, remainder notes documented using (method).”
Patient consented before, but declines use at a later visit
- Do not turn on the scribe for this visit.
- Update the consent status: change the chart flag or field and note the withdrawal.
- Treat the patient’s current preference as governing for this and future visits unless they re-consent.
EMR note: “Patient previously consented to AI scribe; declined at today’s visit. Consent status updated; alternative documentation used (method).”
Vendor engagement
- Confirm with your vendor exactly how patient consent can be logged within the AI scribe (if applicable).
- Confirm how to stop a session mid-visit and what happens to information already captured.
- Confirm whether the tool retains or deletes audio, transcripts, drafts, or other information after finalization, and for how long.
Other considerations
- Document your consent process so that any provider in your clinic can follow it.
- Establish a non-AI documentation process to ensure continuity when AI tools are unavailable.
When this toolkit no longer applies
This toolkit covers only the AI scribe transcription function. Consent must be revisited if the tool’s function changes to include other non-transcription functions. Consent must also be revisited if the vendor’s handling of personal information changes in a way that affects what information is collected, how it is used or disclosed, or the privacy risks involved.
Prior consent should not automatically be relied upon for different uses of the tool.