Glossary, documentation
What is ambient clinical documentation?
Ambient clinical documentation is the use of software that listens to the natural conversation between a clinician and a patient and drafts the clinical note from it, with no dictation or typing during the visit. The clinician reviews, corrects and signs the draft before it enters the record.
Updated . Defined by the wai team for clinics, groups and health systems.
Also called ambient AI documentation, ambient listening or ambient clinical intelligence.
Why Ambient clinical documentation matters to a clinic
Documentation is the part of the working day clinicians most often take home. In one study, clinicians using ambient documentation did 30% less work after hours,1 and that time goes back to patients, to the clinic's list or to home.
For a clinic owner the gain is capacity as well as morale. A clinician who is not typing keeps eye contact with the patient, and a note finished before the next visit means letters and claims leave the same day.
The risk sits in review. An ambient draft can attribute a statement to the wrong speaker or miss a nuance, so the clinic needs a clear sign-off step, consent recorded, and a policy for where recordings and transcripts are kept.
Questions
Is ambient clinical documentation the same as an AI scribe?
Mostly. Ambient clinical documentation names the method, listening to the visit as it happens, and an AI scribe is the software that does it. Most clinics use the two terms for the same thing.
Does the patient have to agree to it?
The clinic tells the patient the visit is being transcribed and records their consent, at booking or in the room. wai keeps that consent on the patient's record with the date. See consent management.
Who checks the note?
The clinician who signs it. Nothing drafted reaches a patient or another clinician before that signature.
Sources
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