AIMC Topic: Documentation

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The Current State of Digital Scribes in Primary Care: A Scoping Review.

Journal of medical systems
The purpose of this scoping review is to explore the current state of digital scribe technology in primary care, focusing on how automatic speech recognition (ASR) and natural language processing (NLP), which are foundational technologies behind arti...

Copy Tools in the Electronic Health Record: Perceptions, Implications, and Future Directions.

JMIR medical informatics
BACKGROUND: Electronic health records (EHRs) can aid in provider efficiency, but may also lead to unintended consequences, such as documentation burden and increased length of notes. To combat issues related to documentation, copying and pasting (CP)...

Artificial Intelligence-Assisted Scribing for Chronic Pain Care: A Narrative Review.

Current pain and headache reports
PURPOSE OF REVIEW: Medical documentation is a significant pillar of healthcare, enabling quality care, legal protection, billing and reimbursement, and collaboration between physicians. However, it is time-consuming and resource-intensive, posing a s...

AI-generated neurology consultation summaries improve efficiency and reduce documentation burden in the emergency department.

Scientific reports
Physicians face a significant documentation burden, spending twice as much time on electronic health records (EHRs) as on direct patient care. Consultation summary reports from the emergency department (ED) are critical for continuity of care and cli...

Artificial intelligence in the non-clinical laboratory: enhancing good laboratory and documentation practices.

International journal of pharmaceutics
Non-clinical laboratories are under increasing regulatory pressure from agencies such as the FDA, EMA, and MHRA to ensure data integrity, traceability, and compliance with Good Laboratory Practice (GLP) and Good Documentation Practice (GDP). While Ar...

Invisible Scribes: Can Nurses Trust Ambient AI for Clinical Documentation?

Journal of continuing education in nursing
Ambient artificial intelligence listening tools promise faster nursing documentation and improved patient engagement, yet they introduce risks of hallucinations, omission, and bias when nurses are excluded from the design and oversight process. Empow...

Health Care Professionals' Experiences and Opinions About Generative AI and Ambient Scribes in Clinical Documentation: Protocol for a Scoping Review.

JMIR research protocols
BACKGROUND: Generative artificial intelligence (GenAI) leverages large language models (LLMs) that are transforming health care. Specialized ambient GenAI tools, like Nuance Dax, Speke, and Tandem Health, "listen" to consultations and generate clinic...

Understanding Clinician Perceptions of GenAI: A Mixed Methods Analysis of Clinical Documentation Tasks.

Journal of medical systems
This mixed-methods study evaluated clinicians' user experience (UX) with Generative AI (GenAI) in Electronic Health Record (EHR) systems across three clinical documentation tasks (Information Extraction, Summarization, and Speech-to-Text) at varying ...

Evaluating the Usability, Technical Performance, and Accuracy of Artificial Intelligence Scribes for Primary Care: Competitive Analysis.

JMIR human factors
BACKGROUND: Primary care providers (PCPs) face significant burnout due to increasing administrative and documentation demands, contributing to job dissatisfaction and impacting care quality. Artificial intelligence (AI) scribes have emerged as potent...

Efficiency and Quality of Generative AI-Assisted Radiograph Reporting.

JAMA network open
IMPORTANCE: Diagnostic imaging interpretation involves distilling multimodal clinical information into text form, a task well-suited to augmentation by generative artificial intelligence (AI). However, to our knowledge, impacts of AI-based draft radi...