Use of ai

Professional standards and ethical codes require client consent before implementing AI-assisted tools in clinical care. You may choose whether to allow AI-assisted documentation in your medical record.

You may decline participation. However, this practice requires consent to AI-assisted documentation as a condition of receiving services here. You are free to seek services elsewhere. Referrals can be provided upon request.

1. AI TOOLS IN USE AT THIS PRACTICE. At this time, this practice only utilizes AI tools available within SimplePractice (the Electronic Health Record software used by this practice to maintain all official records of treatment). These include:

·         Audio recording of sessions (or therapist’s dictation post-session)

·         Transcription of audio recording

·         Generation of a progress note’s first draft

·         Refinement of progress notes

2. HOW RECORDING AND TRANSCRIPTION WORK.

·         Audio is captured only during the therapy session or immediately post-session via dictation

·         A written transcript is generated to assist with clinical documentation

·         Audio recordings are deleted after transcription is generated

·         Transcripts are de-identified in accordance with HIPAA standards, meaning personally identifiable information is removed.

·         The therapist controls when recording begins and ends

·         The therapist reviews and finalizes all notes before they enter the clinical record

·         Audio recordings are never retained as part of the medical record.

Audio recording is used to support accurate clinical documentation and to allow the therapist to remain fully present and engaged during sessions. AI-assisted tools do not replace the therapist’s clinical judgment or responsibility for documentation.

3. DE-IDENTIFIED DATA RETENTION. SimplePractice offers the option to retain de-identified transcripts to improve the accuracy of its AI tools. No identifiable audio or text is retained for this purpose. De-identified transcripts, if retained by SimplePractice, are not part of your medical record. If de-identified retention is not permitted, transcripts are permanently deleted once the session note is signed or after seven (7) calendar days, whichever comes first.

4. DATA SECURITY AND CONFIDENTIALITY. AI transcription tools used within SimplePractice are:

·         HIPAA compliant

·         HITRUST certified

·         Encrypted

·         Governed by signed Business Associate Agreements

·         This practice does not sell Protected Health Information (PHI)

·         This practice does not use PHI for marketing

·         PHI is disclosed only as permitted or required by law

5. RISK OF AI USE. AI tools function only as support and are not used to make clinical decisions independently. No electronic system is completely risk-free. AI tools may occasionally mis-transcribe information. The therapist reviews and finalizes all documentation. There is a small risk of data breach or unauthorized access despite safeguards. If there is a known breach of access or data, you will be informed.

6. CONSENT WITHDRAWAL. You may withdraw consent in writing at any time. Withdrawal of consent will result in termination of services at this practice, and referrals will be offered.

7. QUESTIONS. You are encouraged to ask questions prior to signing this document.