Key points
- In a survey of 2,202 Stanford Health Care outpatients in 2025, 73.6% preferred their clinician to use an ambient scribe at future visits.5
- GMC guidance asks for the detail and outcome of any chaperone discussion to be recorded, including the chaperone's identity and role, or that the offer was made and declined.1
- A mandatory chaperone field fixes the record a systematic review of breast examination found poorly documented even after quality improvement projects.2
- NICE asks menopause clinicians to discuss the benefits and risks of each management option with the person, and the template follows that order.4
- wai drafts the note and the letter for the clinician to review and sign, and the patient decides who sees her record through explicit, revocable permissions.7
Summary
Ask consent at every visit, give the template a mandatory chaperone field for every intimate examination, and give each consultation type its own structure. The clinician hears the whole history without typing, reviews the draft with most care on the sensitive parts, and signs.
The patient tells a hard history to a clinician who never looks away to type, and leaves with a plain-language letter the same day. Templates for gynaecology, menopause and private antenatal care, with a chaperone record that never depends on memory, make it routine.
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Request a demoSee a menopause consultation drafted into a note, a chaperone record and a plain-language letter, in fifteen minutes with a clinician who uses wai daily.
| Visit | Note structure | Must be recorded | Letter |
|---|---|---|---|
| Gynaecology new patient | Presenting problem, menstrual and obstetric history, contraception, screening status, examination, plan | Chaperone offer, outcome and identity | To the patient, copied to the family doctor |
| Menopause review | Symptoms by domain, cycle history, options with benefits and risks, decision | Benefits and risks discussed, in the clinician's words | To the patient, copied to the family doctor |
| Fertility-adjacent consultation | Cycle and reproductive history, investigations so far, plan or onward referral | What was shared with any partner present, with consent | To the referring doctor or fertility clinic, copy to the patient |
| Private antenatal visit | Gestation, scan findings as narrated, symptoms, plan | Main maternity care provider named | To the patient and the main maternity care provider |
| Any intimate examination | Consent, chaperone, findings, what the patient was told | Chaperone identity and role, or offer declined | Chaperone stated where the letter covers the examination |
Consent at every visit
Among 2,202 outpatients surveyed at Stanford Health Care between May and July 2025, 70.1% found an ambient scribe helpful and 73.6% wanted it used at future visits, with small differences by gender, age and race.5
Ask at every visit, since a patient comfortable with recording for a menopause review may want it off for a disclosure about sexual health, pregnancy loss or abuse. Agree how a request to stop recording is handled and noted, and use the same consent wording in every room. The consent guide has a script to adapt.
A chaperone field on every intimate examination
GMC guidance says doctors should record the detail and outcome of any discussion about chaperones, record that a chaperone was present with their identity and role, and where the patient declines, record that the offer was made and declined. A relative or friend is not usually a suitable chaperone, though the patient may still have one present for support.1
A systematic review of ten studies on chaperones in breast examination found poor documentation generally, despite quality improvement projects.2 When one urology team audited itself against GMC guidance, documentation of chaperone use rose by 9.85% in clinical notes and 36.65% in clinic letters.3
Make the chaperone field mandatory and say the offer and the answer aloud, for example offering a chaperone, the patient accepting, and naming the nurse who attends. Read that field first in every review.
Menopause consultations
NICE updated its menopause guideline in April 2026. It asks clinicians to identify perimenopause in otherwise healthy people aged 45 or over with recently started vasomotor symptoms and menstrual changes without laboratory tests, and to discuss the benefits and risks of each management option with the person.4 The template follows that order, symptoms by domain, cycle history, options with their benefits and risks, and the decision.
Take a 49-year-old with eight months of hot flushes and night sweats, irregular periods, poor sleep and low mood at work. The draft lists symptoms under vasomotor, sleep, mood and cycle headings, records her history and blood pressure, and sets out the options discussed, hormone replacement therapy in two forms with the benefits and risks the clinician described, and non-hormonal options. It records her decision to start treatment, with a review in three months.
The letter is addressed to her in plain words and copied to her family doctor. The clinician checks the risk discussion against what was said, puts her own words back where the draft paraphrased, and signs.
Templates for each kind of visit
Gynaecology, menopause, fertility-adjacent and private antenatal visits each have their own structure, set out in the table below. Fertility work with its own consent requirements is covered in AI scribes for fertility clinics.
Every private antenatal letter names the main maternity care provider and is copied to them, so a private scan or review joins the woman's wider record.
Who reads the record
On wai, each member of staff sees only what their role needs, enforced in the database, and every draft, approval and signature on a women's health note is logged and can be exported.6
Her letters and results sit in her own wai Profile, every sharing permission is explicit and revocable, and her data is not sold or used to train external models.7
Where to start
Start with menopause and follow-up gynaecology clinics. Build the templates with a mandatory chaperone field and a consent line, and run them for two weeks. Measure time from the end of clinic to signed letters, and audit every intimate examination note for a complete chaperone record.
Then add new patient gynaecology and private antenatal templates, and repeat the chaperone audit after a month, aiming for a complete chaperone record on every note.
Bring a gynaecology or menopause template you use today and watch a consultation fill it, chaperone field included.
Frequently asked questions
Do patients accept an AI scribe in sensitive consultations?
Most do when asked. In a 2025 survey of 2,202 outpatients, 73.6% wanted ambient scribes used at future visits.5 Ask at every visit and agree how a request to stop recording is handled.
How should a chaperone be recorded?
GMC guidance asks for the detail and outcome of the chaperone discussion, the chaperone's identity and role, or a record that the offer was made and declined.1 Make it a mandatory template field.
Can a partner act as the chaperone?
GMC guidance says a relative or friend is not usually a suitable chaperone, though the patient can still have them present for support.1
What should a menopause note record?
Symptoms by domain, cycle history, the options discussed with their benefits and risks, and the decision, in line with NICE guidance.4
Does the AI scribe work for fertility consultations?
Yes, with its own template and consent rules. See AI scribes for fertility clinics.
Sources
- 1General Medical Council, 2024Intimate examinations and chaperones, GMC professional standards (archived copy read 14 Oct 2026)Read 14 October 2026Read source
- 2Irish Journal of Medical Science, Ou and colleagues, 2024Chaperone in breast examination, a comprehensive systematic review of patient and clinician perspectives, and documentationRead 14 October 2026Read source
- 3Annals of Surgery, Desouky and colleagues, 2024Compliance with GMC guidelines for the use of a chaperone in urology outpatient clinicRead 14 October 2026Read source
- 4National Institute for Health and Care Excellence, 2026Menopause, identification and management (NG23), recommendationsRead 14 October 2026Read source
- 5JAMIA Open, Shah and colleagues, 2026Patient perspectives on clinicians' use of ambient AI scribesRead 14 October 2026Read source
- 6wai, 2026Security at waiRead 14 October 2026Read source
- 7wai, 2026wai Profiles, the patient's own recordRead 14 October 2026Read source
Hear every word, and have the letter ready to sign before she leaves.
Bring a women's health consultation to a fifteen-minute call with a clinician who uses wai daily, and expect an answer to your booking within one working day.
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