The short answer
An AI-generated note needs a clinical review, even when it reads well. Compare it with the entire transcript and any context you supplied, correct missing or unsupported statements, and check the details that could change care. Only then should the reviewed note be transferred to the authorised medical record.
First, confirm the source is complete
Read the beginning and end of the transcript before generating the note. If the final minutes, treatment response or disposition are missing, the note cannot reliably reconstruct them. Correct the transcript or add the information that you know before proceeding.
Where you combine voice, pasted notes, images or PDFs, distinguish what the patient said, what another clinician recorded and what you observed yourself. An extracted document can be incomplete or misread, so check the original source.
Check high-risk facts one by one
Read for meaning as well as grammar. For each important statement, ask whether the source supports it and whether it describes the encounter accurately. Correct any discrepancy before the note is used for care.
- Confirm that the note belongs to the right encounter and gives the correct age. A misheard date is not a reliable way to establish age.
- Check the anatomical site and side throughout the history, examination, investigations, procedures and plan.
- Verify each medicine’s name, dose, route and frequency, and whether it was given, prescribed, considered or withheld. Check allergies and adverse reactions separately.
- Make sure words such as “no”, “possible”, “not yet”, “declined” and “ruled out” retain their intended meaning.
- Compare observations and test results with their numbers and units. Keep completed tests separate from pending ones.
- Check who supplied each finding and when it happened, particularly when the patient received care before arrival.
- Confirm the disposition and follow-up, including who is responsible for any outstanding action.
Look for omissions, repetition and unsupported claims
Compare each section with the source, especially the assessment and plan. A note may sound complete while leaving out a clinically important negative, a treatment response or a pending result. Repetition can also obscure the actual sequence of care.
Do not let a generated note turn a question into a diagnosis, a proposed test into a completed result, or a planned follow-up into an appointment already made. If the source is ambiguous, keep that uncertainty visible until the clinician resolves it.
Finish in the authorised clinical record
After reviewing, copy the final note into the organisation’s approved clinical system and follow local processes for signing, dating and correcting records. DictaMed’s temporary draft is not the permanent medical record.
The Medical Board of Australia expects records to report relevant clinical history, findings, investigations, diagnosis, information given to patients, medicines and management in a form another practitioner can understand. That standard remains the clinician’s responsibility when using AI assistance.
Common questions
Can I use the note if it reads professionally?
Only after checking it against the source and encounter. Professional wording does not establish accuracy.
What should I do if the transcript is incomplete?
Add or correct the missing source information first. Do not ask the model to guess the missing clinical facts.
Does DictaMed replace the medical record?
No. It prepares a temporary draft for practitioner review and transfer to the authorised record.
Sources and product details
These guides describe DictaMed’s current workflow and general documentation principles. Follow your workplace policy and use clinical judgement for each patient.