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Changing Practice Together

  • Nurses
  • Practice development leads
  • Practice supervisors

Person-centred checks for AI-drafted notes

Most checks of AI-drafted notes ask whether the note is accurate. That matters, but it is not enough. A note can be accurate and still lose the person: their words, their priorities, and the nurse's reasoning about their care.

These five checks help nurses and teams review notes drafted with AI, such as those from an AI scribe, against person-centred practice. They draw on the person-centred processes in the Person-centred Practice Framework (McCance and McCormack, 2021).

You are still accountable

You must review, correct and approve any AI-drafted note before it becomes part of the record. Follow your organisation's policy on AI tools and the NMC Code on record keeping.

The five checks​

  1. Beliefs and values are visible. Does the note show what matters to the person, in their terms?
  2. Goals sound like the person, not the template. Are the person's goals written as they expressed them, rather than in standard phrases?
  3. Shared decision-making is recorded, not implied. Does the note show the options discussed, consent, how understanding was checked and the person's preference?
  4. Safeguarding and vulnerability are not summarised away. Are disclosures, concerns about risk and the person's vulnerability recorded in full and accurately?
  5. The nurse's clinical reasoning is explicit. Can a colleague see what you assessed, what you concluded and why?

Three ways to use the checks​

When you approve a note​

Read the AI-drafted note against the five checks before you approve it. Add or correct anything that is missing. This takes a minute or two and becomes quicker with practice.

As a team audit​

Review a sample of anonymised AI-drafted notes as a team, for example five notes a month. Use the record sheet below and discuss patterns rather than individual notes.

In supervision​

Bring a note you found difficult to correct to clinical supervision. Explore what the tool missed or changed, and what that tells you about your practice and the tool.

Record sheet​

Use anonymised notes only. Score each check as Yes, Partly or No.

CheckYes / Partly / NoWhat was missing or changed?
1. Beliefs and values are visible
2. Goals sound like the person
3. Shared decision-making is recorded
4. Safeguarding and vulnerability are recorded in full
5. Clinical reasoning is explicit

Accuracy: were there any factual errors, such as wrong medicines, doses, names or attributions of who said what? If so, report them through your organisation's incident or AI reporting route.

Questions for team discussion​

  • Which checks are most often missed? Why might that be?
  • Does the tool work less well for some people, for example those with a strong accent, a speech difference or a learning disability, or when an interpreter is present?
  • Has the presence of the tool changed what people tell us?
  • Are we spending the time saved with the people we care for?

Asking the person​

Where appropriate, ask the people you care for:

  • Did you feel listened to?
  • Did having the AI tool in the room change what you felt able to say?
  • Does the summary of our conversation sound like you?

Reference​

  • McCance, T. and McCormack, B. (2021) The Person-centred Practice Framework. In McCormack, B. et al. (eds) Fundamentals of Person-centred Healthcare Practice. Chichester: Wiley Blackwell, chapter 3.