KNOWLEDGE BASE
PROCEDURE
AI-Assisted Clinical Transcription Procedure
Document No:
PROC-006
Version:
1.0
Approved by:
Management
Effective Date:
30/06/2026
Review Date:
30/06/2027
Purpose
These procedures outline the operational requirements for obtaining, recording, managing, and withdrawing patient consent for the use of the clinic's approved AI-assisted clinical transcription service.
These procedures must be read in conjunction with the AI-Assisted Clinical Transcription Policy.
Responsibilities
Reception Staff
Reception staff are responsible for:
obtaining and retaining written consent documentation
maintaining consent records within the Patient Management System (PMS)
processing consent withdrawal requests
updating consent status flags within the PMS
Clinical Staff
Practitioners are responsible for:
confirming consent status prior to use
obtaining verbal consent before each consultation
documenting verbal consent within the clinical record
ensuring appropriate use of the transcription service
reviewing and finalising all clinical notes
Initial Consent
New Patients
Written consent is obtained as part of the patient intake process.
Upon receipt of a completed new patient form:
The PMS consent status is updated to reflect the patient’s consent or non-consent, ie. Heidi✓ or Heidi✗
The consent document is retained in accordance with clinic record retention procedures.
Existing Patients
Where a patient has not previously provided consent:
The patient is provided with the approved Heidi Consent Form.
The completed form is returned to reception.
The PMS consent status is updated to reflect the patient’s consent or non-consent, ie. Heidi✓ or Heidi✗
Consent Verification Prior to Consultation
PMS Verification Procedure
Prior to activating the transcription service, practitioners must:
Confirm that the PMS status displays: Heidi✓ or Heidi✗
If PMS status is Heidi✓, proceed with verbal consent procedure.
Verbal Consent Procedure
Verbal consent must be obtained prior to each consultation where the transcription service is used.
Recommended wording:
"I'm ready to turn on Heidi. Are you happy to go ahead?"
If the patient agrees:
The practitioner activates the transcription service.
The practitioner records in the clinical notes: "Verbal consent obtained for use of Heidi transcription service."
If the patient declines:
The transcription service must not be activated.
The consultation proceeds without use of the service.
The practitioner advises reception following the consultation.
Reception provides the patient with an Opt-Out Form for completion.
Withdrawal of Consent
Patients may withdraw consent at any time.
Withdrawal requests must be retained and recorded in the PMS.
Electronic Withdrawal
Where a withdrawal request is received electronically:
PMS status is updated to: Heidi✗
The withdrawal documentation is retained in the patient record.
In-Person Withdrawal
Where a patient advises that they no longer wish to participate:
The practitioner immediately ceases use of the transcription service.
Reception provides the approved Opt-Out Form.
The patient completes and returns the form.
The completed form is retained in the patient record.
PMS status is updated to: Heidi✗
Minors
For patients under 18 years of age, consent must be provided by a parent or legal guardian.
The signed consent form must be retained in the patient record.
Third Parties Present During Consultation
Where another person is present during a consultation, including:
parent
guardian
carer
support person
interpreter
student practitioner
the practitioner must:
Inform the individual that the transcription service will be used.
Obtain verbal consent before activating the service.
If consent is not provided, the transcription service must not be used.
Appropriate Use
The transcription service may only be used:
during private clinical consultations
where required consent has been obtained
for clinical documentation purposes only
The transcription service must not be used:
in open gym or shared treatment areas
during staff meetings
during supervision sessions
during HR discussions
during administrative meetings
where consent has not been obtained
End of Consultation Procedure
At the conclusion of each consultation, practitioners must:
Confirm the transcription session has ended.
Review the generated documentation.
Edit and verify the content for accuracy and completeness.
Finalise the clinical note within the patient record.
Practitioners remain solely responsible for the final clinical record.
Annual Review
Consent remains valid until withdrawn.
The clinic may periodically review consent records and obtain updated consent where operational, legal, technological, or regulatory changes occur.