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AI scribe and when an authorization is required

AI Scribe and when a patient authorization is required

There has been some confusion about when a patient authorization is required when using AI scribe or the recording of a patient encounter.

HIPAA permits providers to use and disclose PHI for the Treatment, Payment, and Healthcare operations (TPO). If the provider records the encounter solely to create clinical documentation, then a separate patient authorization is required.

Keep in mind, you must have a signed business associate agreement (BAA). The recording must be secure, and encryption and proper safeguards are in place. Also, this must be disclosed to the patient.

HOWEVER, it is recommended to obtain a patient authorization since many states, including Florida require an authorization from BOTH parties to record audio conversations.

AI Scribe Used for Treatment Documentation

If the provider records the encounter solely to create clinical documentation for treatment, payment, or healthcare operations purposes, HIPAA generally does not require a separate patient authorization.

Medical Provider Requirements

The AI vendor must sign a Business Associate Agreement (BAA). The recording must be secured using encryption and proper technical safeguards.

When Authorization May Be Required

A separate written authorization may be required if the recording is used for marketing, shared outside of treatment purposes, or training outside HIPAA regulated entities.

Some state law requires two-party consent for audio recording (such as Florida).

State wiretapping laws may require patient consent even if HIPAA does not.

AI scribing tools typically record audio of patient encounters, transcribe and process PHI, sometimes store or analyze recordings. That triggers BOTH laws at the same time.

Additional Risk Considerations

Even if HIPAA does not require authorization, patients should be clearly informed that the visit is being recorded. Transparency reduces complaints and scrutiny. Even some malpractice carriers recommend a written acknowledgment.

Practical Best Practice

Providers should be updating their intake paperwork to include this disclosure and adding signage in the exam rooms.

Aris Medical Solutions helps medical practices and business associates understand HIPAA expectations and reduce risk.

Our HIPAA Keeper™ was designed to help organizations:

  • Understand where they stand
  • Organize required documentation
  • Maintain compliance over time
  • Be prepared if questions ever arise

Additionally, you will have a HIPAA security analyst to guide and assist you step by step.

To find out where you stand with your compliance, schedule a free HIPAA checkup today at Aris Medical Solutions.

About Suze Shaffer

Suze Shaffer is the Owner and President of Aris Medical Solutions, a healthcare compliance company dedicated to simplifying HIPAA compliance. Through its online compliance solution, the HIPAA Keeper™, Aris Medical Solutions provides healthcare providers and business associates with the tools, documentation, training, and expert guidance needed to achieve and maintain HIPAA compliance.

Through the HIPAA Keeper™, Aris has assisted organizations nationwide with conducting risk analyses, developing risk management plans, implementing HIPAA Privacy and Security policies and procedures, and strengthening safeguards for protected health information. Aris Medical Solutions also considers applicable federal and state privacy and security requirements to help clients build a more comprehensive compliance program.

Suze is also a speaker and has presented at numerous conferences and professional events on HIPAA compliance, cybersecurity, risk management, and data breach prevention. Helping organizations understand their responsibilities and identify vulnerabilities before they result in a breach, audit, or investigation. She believes effective compliance begins with education. By helping organizations understand not only what they are required to do, but why those safeguards are important, organizations are better prepared to protect patient information and reduce their compliance risks.

At Aris Medical Solutions, the mission is simple: “Simplifying HIPAA” through education, expert guidance, and the HIPAA Keeper™, Aris Medical Solutions helps organizations turn complicated compliance requirements into a manageable, ongoing process.

The information provided reflects regulatory requirements and guidance available at the time of writing and is intended for educational purposes only. It should not be considered legal advice.

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