KNOWLEDGE BASE
POLICY
AI-Assisted Clinical Transcription Policy
Document No:
POL-011
Version:
1.0
Approved by:
Management
Effective Date:
30/06/2026
Review Date:
30/07/2027
Purpose
This policy outlines the approved use of AI-assisted clinical transcription services within Bodyfocus Wellness Centre, including practitioner responsibilities, consent procedures, privacy requirements, and documentation standards.
The purpose of the service is to support clinical documentation efficiency and accuracy while maintaining patient privacy, confidentiality, and professional standards.
AI-assisted transcription is a support tool only and does not replace practitioner clinical judgement, responsibility, or professional record-keeping obligations.
Scope
This policy applies to all employees and contractors authorised to use the clinic’s approved AI-assisted clinical transcription service.
For the purposes of this policy, “practitioners” includes all employees and contractors using the service.
Policy Statement
Bodyfocus Wellness Centre permits the use of approved AI-assisted clinical transcription services to support clinical documentation.
Only clinic-approved services may be used for clinical documentation purposes.
At the time of publication, the approved provider is Heidi Health Australia.
Employees and contractors must not use personal AI accounts, public AI platforms, or unapproved transcription tools for clinical documentation purposes.
AI-generated content is a drafting tool only and practitioners remain fully responsible for:
The accuracy, completeness, and appropriateness of all clinical documentation.
Reviewing and editing all AI-generated content prior to inclusion in the clinical record.
Ensuring documentation complies with professional, legal, and privacy obligations.
Ensuring appropriate consent has been obtained and documented prior to use.
Consent Requirements
Written patient consent must be obtained prior to the first use of the transcription service during a consultation.
Patients must be informed that:
Use of the service is voluntary.
Declining consent will not affect their care.
Consent may be withdrawn at any time.
The service assists with clinical documentation only.
In addition to written consent, verbal consent must be obtained at each consultation prior to activating the transcription service.
If verbal consent is not provided, the service must not be activated.
Withdrawal of Consent
Patients may withdraw consent at any time.
Withdrawal requests must be provided in writing and retained within the patient record.
If consent is withdrawn during a consultation, transcription must cease immediately.
Once consent has been withdrawn, the service must not be used in future consultations unless new written consent is obtained.
The patient’s consent status must be clearly recorded within the Patient Management System and checked prior to each use of the service.
Privacy, Confidentiality and Data Security
Use of the transcription service must comply with:
Privacy Act 1988 (Cth)
Health Records and Information Privacy Act 2002 (NSW)
Applicable professional obligations relating to confidentiality and health records
Practitioners must:
Use only clinic-approved accounts and devices.
Maintain secure passwords and access controls.
Ensure devices are protected against unauthorised access.
Avoid use of the service in circumstances where unrelated individuals may be unintentionally recorded.
Ensure the transcription service is deactivated immediately at the conclusion of the consultation.
Personal USB devices, external storage devices, or unauthorised software must not be connected to clinic systems where this may introduce cybersecurity or data security risks.
The approved transcription service does not retain consultation audio recordings.
Appropriate Use
The transcription service may only be used for legitimate clinical documentation purposes.
The service must not be used for:
Staff discussions.
Administrative meetings.
Supervision or HR discussions.
Non-clinical conversations.
Consultations where consent has not been obtained.
Group or open clinical settings where unrelated individuals may be captured without consent.
Practitioners may elect not to use the service where its use may adversely affect patient comfort, privacy, therapeutic rapport, or clinical appropriateness.
Minors and Third Parties
Where required by law or clinic policy, consent for minors must be obtained from a parent or legal guardian.
Where another person is reasonably likely to be present during the consultation, practitioners must ensure those individuals are informed prior to activation of the service.
Training and Compliance
Practitioners must complete any required training prior to using the transcription service.
Failure to comply with this policy may result in removal of access to the service and/or disciplinary action in accordance with organisational policies and procedures.
Responsibilities
Management
Management is responsible for:
Approving AI-assisted transcription services.
Maintaining consent processes.
Ensuring staff training is provided.
Monitoring compliance with this policy.
Practitioners
Practitioners are responsible for:
Obtaining and documenting consent.
Using the service appropriately.
Reviewing and verifying all generated documentation.
Maintaining patient privacy and confidentiality.