How should a nurse practitioner document a consultation with an AI scribe?

The short answer: get the patient's consent to recording and note it, run the consult as you normally would, say your plan out loud before the patient leaves, and check the draft before you sign it. In NP practice, four parts of the note carry most of the risk: medication changes, investigations and results, safety-netting advice, and follow-up. Those are the lines to read closely.

This article walks through each step, with a fictional example, and applies whichever scribe you use. We build Hanah for nurse practitioners, and the last section explains how it handles all this. Read that part knowing who wrote it.

What does an NP consultation note need to show?

It needs to show the whole episode: what you assessed, what you concluded, what you did or prescribed, what you told the patient, and what happens next.

In Australia, the NMBA's Nurse practitioner standards for practice expect NPs to advise patients on a treatment's benefits, side effects, interactions and follow-up, to follow up investigation results in an appropriate time frame, and to monitor, evaluate and document treatments. If you bill Medicare, the MBS Online factsheet on NP items notes that compliance checks may ask for adequate and contemporaneous notes of the time spent with the patient. That matters, because NP attendance items are defined by consultation length.

In the UK, section 10 of the NMC Code asks you to complete records at the time or as soon as possible afterwards, to record risks and the steps taken to deal with them, and to attribute, date and time every entry.

An AI scribe changes who types the first draft. None of these obligations change.

How should you handle consent before you press record?

Ask before you start, explain what the scribe does and where the recording goes, and note the patient's answer in the record.

Ahpra's guidance on AI in healthcare says a generative AI scribe will generally need the patient's informed consent, that recording a consultation without it may have criminal implications, and that you should ideally note the patient's response in the health record. In New Zealand, the Health Information Privacy Code 2020 sets the rules for collecting health information, including what patients have to be told.

One line at the top of the note covers it: "Consent to AI-assisted recording obtained." If the patient declines, don't record.

What goes in each part of a SOAP note?

SOAP suits NP consults because its four sections follow the way you work: assess, diagnose, plan.

• Subjective: the presenting concern, relevant history, current medicines and how they're being taken, allergies, and any side effects the patient reports.
• Objective: what you measured or examined, with figures and units, and any results you reviewed.
• Assessment: your working diagnosis or impression, and how it has changed since last time.
• Plan: medication changes, investigations ordered, referrals, advice and safety-netting, and the review interval.

If you'd prefer a separate Medications heading, add one. Medication changes in their own section are easier to find and easier to check.

How should medication changes be written?

Write each change so another clinician could act on it without asking you: the medicine, dose, route and frequency; whether it's new, changed, continued or stopped; why; what you told the patient about side effects; and what you'll monitor.

A scribe can only write what it hears. The most reliable habit is to say the change out loud, in full, the way you'd write it: "We'll keep perindopril at 2.5 milligrams once a day." A vague "let's keep going with that" leaves the draft to guess, or to leave the line out.

Drug names and doses are where a transcription error does the most harm, so check them against what you actually prescribed. Ahpra's guidance is explicit that checking the accuracy of an AI-assisted record is your responsibility.

How do you document safety-netting?

Record what you told the patient to watch for, what to do if it happens, and how urgently. "Safety-netting advice given" on its own doesn't show what the advice was.

The scribe captures this best when you say it plainly to the patient, which is good practice anyway. A short spoken summary at the end works well: what we found, what we're doing, what to watch for, and when I'll see you. That gives the scribe everything the Plan section needs.

How should follow-up, results and referrals be recorded?

Note the review interval, the tests you ordered, and who will follow up the results. Under the NMBA standards, the NP who requests an investigation is responsible for interpreting it and acting on it, so the note should show that loop is closed.

For referrals, record in the note who you're referring to and why, then write the letter from the same consult rather than from memory.

What does this look like in practice?

Here's a fictional review, for illustration only; it isn't clinical guidance. At the last visit the patient's clinic blood pressure was 150/95, they started perindopril 2.5 mg daily, and they've been keeping a home diary since.

Near the end of the consult, the NP says: "Your reading today is 140 over 88, and your home readings average about 138 over 86, a bit higher in the mornings. No dizziness, and you're taking it with breakfast. We'll keep perindopril at 2.5 milligrams daily and check your kidney function and potassium with a blood test this week. I'll call you with the result. If you feel faint or dizzy when you stand up, sit down and call me. If your lips, face or tongue swell, call triple zero. If you get a dry cough, let me know. I'll see you in four weeks with the diary."

A draft from that consult, in shorthand, might read:

S: Consent to AI-assisted recording obtained. BP review after starting perindopril 2.5 mg daily. Home BP avg 138/86, higher AM. Taking with breakfast. No dizziness.

O: Clinic BP 140/88. Home diary reviewed.

A: Hypertension, improving on current dose.

P: Continue perindopril 2.5 mg daily. UEC this week; NP to phone with result. Advised: dizzy or faint on standing, sit and contact NP; lip, face or tongue swelling, call 000; report new dry cough. Review 4/52 with home BP diary.

Everything in that draft comes from something said in the room. Just as important is what it leaves out: there's no line saying lifestyle advice was given, because none was given in this consult. A scribe that adds one is recording care you didn't provide.

What should you check before you sign?

• Medicines: names, doses, frequencies, and whether each is new, changed, continued or stopped.
• Numbers: readings, results, units, and left or right.
• Additions: anything in the draft you didn't say or do. Delete it.
• Omissions: anything you said that's missing, especially safety-netting and the review interval.
• Attribution: a symptom the patient denied mustn't appear as present.
• Consent: the line recording it.

How does Hanah handle this?

When you sign up as a nurse practitioner, Hanah starts you with a SOAP consultation note, a referral letter and a care plan. The note starts in shorthand, and you can switch it to standard or full prose. You can edit the starter, add a Medications heading, or bring your own Word or PDF template.

Hanah's drafting instructions tell the model to use only the current consult for clinical facts, not to infer or invent them, and to leave out sections with nothing to put in them. The draft streams onto your screen as it's written. If you use Cliniko, Halaxy, Nookal or Zanda, it opens for your review inside your practice-management system before it goes into the note. The referral letter comes from the same consult.

The safety-netting you said out loud can also reach the patient in writing, as a plain-language message you review and send, alongside a care plan they can read in the Hanah patient app.

We publish our measured accuracy and hallucination results, and the Australian Trust Centre lists our controls and subprocessors. New Zealand and UK have their own.

FAQ

Can an AI scribe make the diagnosis for me? No. Ahpra's guidance says practitioners must apply human judgement to any AI output and remain responsible for the care they provide. The Assessment should record your judgement. Treat anything in it that you didn't say as an error and remove it.

Do I need consent every time? Ahpra frames consent around recording the consultation. Asking at each consult and noting the answer is the simplest way to show consent was given for that recording. Your practice's policy and your state or territory's recording laws also apply.

What if the patient doesn't want to be recorded? Don't record. A scribe drafts from whatever it hears, so you can dictate a summary once the patient has left and let the scribe draft from that instead.

Is the transcript part of the record? The note you sign is the record. How long audio and transcripts are kept varies by vendor, so ask, and check it against your own record-keeping obligations.

Does this apply in New Zealand and the UK? The steps are the same. The standards are set by the Nursing Council of New Zealand and the NMC respectively.

If you'd like to see this with your own templates, see Hanah for nurse practitioners or book a demo below.