Ambient documentation tools produce three different things from one recording, and they are not equally trustworthy. A history of present illness is a restatement of what was said; the model heard it. A mental state examination is an observation you made and mostly did not narrate — so the model is inferring affect, psychomotor state and rapport from a transcript that never contained them. An assessment and plan is a formulation, which is reasoning rather than record.
The practical rule is to review them in reverse order of how much the model had to invent. Skim the history, read the mental state examination word by word, and write or rewrite the formulation yourself.
Word choice carries therapeutic and legal weight in psychiatry more than in most specialties — 'guarded' and 'evasive' are not synonyms, and a note that says the patient denied suicidal ideation is a different document from one that says the topic was not raised. Whatever the tool produced, the signature makes it yours.
- Check the mental state examination line by line for observations you did not make.
- Write the risk assessment yourself, every time.
- Tell the patient the tool is recording, and record that you told them.
- Watch for absent findings asserted as negatives — 'no thought disorder' when the topic never arose.
- Agree with your service which sections the tool may draft at all, rather than leaving it per clinician.
Why it matters
The section of a psychiatric note that a scribe is least able to produce is the one it produces most fluently.
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