Standard Operating Procedure (SOP): Use of AccuRX Scribe Technology

1. Purpose

This document outlines the standard operating procedure for the use of an AI scribe tool in general practice appointments. It is designed to ensure safe, ethical, and transparent use of the technology, with appropriate communication and consent from patients.

2. Scope

This Standard Operating Procedure (SOP) applies to all clinical and administrative staff involved in the use of the AI scribe system in patient appointments, as well as patients who may be affected by its use.

3. Overview of the Technology Use

The AI scribe will be used to:

• Listen to live appointments (audio only) via a secure microphone connection.
• Generate real-time or near-real-time summaries of the appointment to support clinical record-keeping.
• Assist clinicians with drafting letters, such as referral or follow-up letters, based on the appointment.

4. Step-by-Step Process for Use

4.1 Set-Up

• The AI scribe tool is installed and integrated with the practice’s IT system.
• Devices (e.g. microphones or headsets) are securely configured in each appointment room.
• Access is limited to trained users (clinicians and authorised staff).
• Data security and GDPR compliance measures are in place, including end-to-end encryption and no long-term storage of audio.
• AI Scribe is limited for fully qualified GPs to use only in Woodhouse Health Centre
• AI Scribe will be used during face to face appointments only
• Use will be only in the premises of Woodhouse Health Centre, not for use at home
• All GPs will complete the AI Scribe onboarding webinar prior to use and confirm they have read the Standard Operating Procedure (SOP)

4.2 Before the appointment

Signs are displayed in reception and appointment rooms notifying patients of the use of AI scribe technology during face to face appointments

Practice website and social media provide a plain-English explanation of how the AI scribe works, why it’s being used, and how patients’ data is protected.

4.3 Gaining Patient Consent

As the patient enters the appointment, the clinician will:

• Explain that an AI tool will be used to listen and help summarise the appointment.
• Confirm that the audio will not be saved or reviewed by a third party but the transcription is saved for a defined period of time which will be set at 30 days but this length of time is under review
• Ask for verbal consent to proceed with the AI scribe running.
• It will be documented in the notes that AI has been used to summaries these appointments

4.4 During the appointment

• The AI listens to the conversation between clinician and patient.
• It generates a real-time summary or transcript draft for the clinician to review after the appointment.
• No audio is stored beyond the immediate session.
• A transcript of the appointment will be saved for a defined period of time (initially 30 days)
• The clinician remains in full control of what is entered into the official patient record and will review all summarised notes before making appropriate changes and saving.
• Clinicians remain responsible for entering SNOMED codes.

4.5 At the end of the appointment

• The clinician reviews and edits the AI-generated summary before saving it into the patient’s medical record.
• Any letters generated (e.g. referrals) are also reviewed, edited, and approved by the clinician.

5. Communication and Public Information

To ensure transparency and maintain trust:

• A detailed explanation is available on the practice website and shared via social media.
• Posters in the waiting room and appointment rooms provide key points and consent reminders.
• Staff are trained to answer common questions from patients.

6. Data Protection and Risk Management

• The AI Scribe software used meets NHS DSPT (Data Security and Protection Toolkit) requirements.
• A DPIA (Data Protection Impact Assessment) has been completed.
• No recordings are stored. The AI operates in real-time, and all summaries are reviewed by clinicians.
• The tool is subject to ongoing evaluation for safety, accuracy, and patient feedback both by the software manufacturer and within Woodhouse Health Centre.

7. Review and Feedback

• Regular review meetings will be held to evaluate the tool’s impact on documentation quality and patient safety via Partnership meetings
• Entries will be audited for accuracy and the correct saving of notes within 3 months of implementation and then at 6 to 9 months to ensure no harm has come to patients
• Feedback from clinicians will be collected and used to improve the process at Woodhouse Health Centre clinical meetings
• Patients will be asked for their feedback via the PPG
• Any incidents or data concerns will be logged and investigated according to the practice’s Information Governance policies.