Guide

Patient Consent for AI Medical Scribes

Before you record a patient encounter with an AI medical scribe, you need consent. Here's what the regulations say (CPSO, CMPA, US state boards), exactly what to tell patients, and how to document the consent so it stands up to scrutiny. Free consent form template at the end.

The short rule

Consent must be: (1) informed (patient understands what AI is doing), (2) voluntary (no pressure to consent), (3) documented (you can prove it later), and (4) jurisdiction-appropriate (Canada vs US, province vs state). Most regulatory bodies converge on these principles.

If you're using Scribeberry or any modern AI scribe, the platform includes a consent-first workflow — but the clinician is still responsible for the consent conversation itself.

Canada — CPSO and CMPA guidance

The College of Physicians and Surgeons of Ontario (CPSO) and the Canadian Medical Protective Association (CMPA) both require explicit patient consent before audio recording in clinical encounters. Their 2024 joint guidance specifies: verbal consent is acceptable but written or documented verbal is preferred.

Provincial colleges (CPSA Alberta, College of Physicians and Surgeons of BC, etc.) generally align with CPSO. Quebec adds Law 25 requirements — see your jurisdiction's specific guidance.

United States — state medical boards and HIPAA

Most US state medical boards (Texas Medical Board, Medical Board of California, etc.) require informed consent for clinical audio recording but defer the specific consent language to the practice. HIPAA itself doesn't mandate explicit consent for the AI scribe use case, but it requires a BAA with the vendor.

Some states (Florida, Maryland, Washington — "two-party consent" states) require consent from all parties to a recording. Even in one-party states, clinical recording warrants the same standard.

What to actually say to the patient

Suggested verbal script: "I use an AI tool that listens to our conversation and helps me write your medical note. No audio is permanently stored, the AI doesn't replace my clinical judgment, and your data stays in [Canada / US] and is never used to train AI models. Are you OK with me using it today?"

Wait for a clear yes. Document the consent in the chart (most AI scribes auto-document this). If the patient declines, switch to manual note-taking for that encounter — never coerce.

Best practice: log a structured consent attestation in the chart — "Patient verbally consented to AI-assisted documentation on [date], [time], using [Scribeberry / other tool]." Scribeberry automatically captures this when you start a scribe with the consent workflow enabled.

Keep the consent record for the same duration as the clinical record (typically 7-10 years depending on jurisdiction).

Special populations

Minors: consent comes from the parent/guardian. For adolescents 14+, jurisdictions vary on the assent requirement.

Capacity-impaired patients: consent comes from the substitute decision-maker. Be especially conservative with AI tools in geriatric and psychiatric settings.

Telehealth visits: same rules apply. Verbal consent at the start of the call is standard.

Scribeberry provides a free patient informed consent form template (PDF, English) suitable for both Canadian and US clinics. Download it at /docs/patient-informed-consent-form.pdf and adapt to your jurisdiction.

If you're an enterprise customer, contact your account manager for translated versions (French, Spanish, Mandarin, Punjabi, Arabic) and white-labeled formats.

How to obtain patient consent for AI medical scribe use

Four-step workflow to obtain compliant patient consent before recording a clinical encounter with an AI medical scribe.

Explain what the AI tool does. In plain language, describe that an AI tool will listen, transcribe, and help generate the clinical note. Mention that the clinician (you) remains responsible for the note.
Confirm data handling. State that audio is not permanently stored, data stays in [Canada/US], and is never used to train AI models.
Ask for explicit consent. Ask the patient: 'Are you comfortable with me using this AI tool during our visit?' Wait for a clear verbal yes.
Document the consent. Log the consent in the chart with date, time, and tool used. Most AI scribes (including Scribeberry) auto-document this when the consent workflow is enabled.

Frequently asked questions

Do I need written consent or is verbal enough?

Verbal consent is acceptable in most Canadian and US jurisdictions for AI scribe use. CPSO and CMPA both accept documented verbal consent. Some clinics standardize on written consent for record-keeping clarity. Always check your local regulatory body.

What if the patient refuses?

Respect the refusal. Document that the patient declined AI-assisted documentation, and chart the encounter manually. Never pressure a patient to consent. This is both an ethical and a legal requirement.

Does the AI scribe record audio permanently?

Reputable AI scribes (Scribeberry, DeepScribe, Suki) do NOT permanently store audio — they stream it for transcription and discard immediately. Only the transcript and the final note are retained. Always confirm with your vendor's data retention policy.

What about Quebec Law 25?

Quebec's modernized privacy framework (Law 25) requires explicit consent for AI processing of personal information and additional disclosure about cross-border data transfers. Use a Quebec-specific consent form that explicitly addresses data residency. Scribeberry is Law 25 compliant.

Can I use an AI scribe with minors?

Yes, but consent comes from the parent or guardian (and from the minor patient as well in adolescent assent jurisdictions). For pediatric practices, build the consent question into your standard intake form.