An AI tool can draft a letter, pull a result into a summary or suggest a next step. Each output needs a different check. A draft letter needs to reflect what actually happened. A recommendation needs to fit the patient in front of you. The General Medical Council (GMC) says doctors remain responsible for the decisions they take when using AI. The people involved in developing, testing and updating a tool remain responsible for that work. GMC guidance on artificial intelligence and innovative technologies.
What to check before using the output
Good medical practice requires doctors to work within their competence, keep up with guidance and base care on an adequate assessment of the patient. Investigations and treatment must reflect that assessment and the doctor’s clinical judgement. The GMC requires doctors to base treatment on the best available evidence. For AI, start by checking what your organisation has approved the tool to do and whether you understand its limits well enough to spot when its output needs closer scrutiny. Keep identifiable patient information within systems authorised for that purpose. Good medical practice, paragraphs 1–7, GMC confidentiality guidance.
For a recommendation about an individual patient, check the inputs that could change the decision. Were the dates, medicines, allergies and results current? Did the system overlook information from a letter or earlier consultation? If it cites a guideline, open the original source and check the passage, its date and whether it applies to this patient. Where the data is incomplete or the output conflicts with the clinical picture, resolve the discrepancy through the record, examination, evidence or advice from a colleague as appropriate. These are practical ways to apply the GMC’s existing standards. Good medical practice, paragraphs 6–7, NHS Resolution guidance on AI and clinical negligence.
For an ambient scribe, check the draft against the encounter before saving a note or sending a letter. Look for missing negatives, wrong doses, statements attributed to the wrong person, and advice or examination findings that the draft added. Check that the actions and follow-up are the ones you actually agreed. NHS England calls for correcting inaccuracies before filing and describes indicating scribe assistance in the finished output as good practice. NHS England guidance for staff using ambient scribes.
What to discuss with the patient
For AI that informs a decision about care, the GMC asks clinicians to discuss the use of the technology, other options and relevant uncertainties or limitations so the patient can make an informed decision. Explain the role it played in terms the patient can use. If a risk tool was evaluated in a different population and that limits the confidence you place in its estimate, explain what that means for the choices on offer. The detail should reflect what matters to the patient and the risk, uncertainty and complexity of the decision. GMC AI resource, GMC guidance on taking a proportionate approach to consent.
For ambient scribing in England, tell the patient at the start what the approved scribe does and give them a chance to decline. NHS England’s information governance guidance says implied consent under the common law duty of confidentiality can apply for individual care. If the patient objects, take notes without the scribe. The GMC’s separate guidance requires consent for recordings covered by paragraph 13, subject to the exceptions it sets out, and gives rules on how to handle recordings made as part of care. Follow the approved local workflow and check with your information governance lead if you are unsure which requirements apply to the way it captures or retains audio. NHS England guidance on ambient scribing consent, GMC guidance on recordings made as part of care.
What belongs in the clinical record
The GMC requires clear, accurate, contemporaneous and legible records, with detail proportionate to the case. Record the relevant findings, information shared, decisions and agreed actions, who made them and when to review them. This includes a decision to take no action. The record should identify who created it and when. Where an AI output materially affected the assessment or plan, a practical approach is to record its role, the important check or discrepancy, and why you chose the final action. Follow any local requirement to record the tool or version. Good medical practice, paragraphs 69–71, GMC guidance on recording decisions.
In a fictional review for a patient with chronic kidney disease and type 2 diabetes, a GP might use an AI reference tool to look up what estimated glomerular filtration rate (eGFR) measures. That is background reading. A patient-specific tool suggests a repeat metformin prescription based on an older eGFR of 48. The GP checks the dated lab report, finds the latest eGFR is 27, and checks NICE NG28, which lists metformin as contraindicated in chronic kidney disease at an eGFR below 30. The GP checks the medicine and result against the patient’s record, speaks to the pharmacist and agrees the immediate plan with the patient. NICE NG28, recommendation 1.9.3.
AI tool suggested a metformin repeat based on earlier eGFR of 48. Latest eGFR 27 mL/min/1.73 m², checked in lab report. Reviewed NICE NG28 and discussed with pharmacist. Agreed with patient to hold metformin. Duty GP to call today to review renal function and diabetes medicines. Patient to contact practice if no call by 4 pm.
If a scribe helped draft the note for that same visit, a brief disclosure can sit alongside the clinical details.
Discussed ambient scribing before use. Note drafted with scribe assistance and checked by the clinician before filing.
Use the separate safety reporting system for the medication tool’s use of an outdated result if it meets local incident or near-miss criteria. Record the tool and version if available, the discrepancy, whether any action was taken on the output, and who was notified. Keep supporting material through approved channels. GMC guidance on raising a concern, paragraphs 11–15, NHS Resolution guidance on AI audit trails.
Frequently asked questions
Do I need to log every AI use in the patient’s notes? The GMC sets a proportionate record standard. Follow local rules for the tool you used. If its output affected care, explain that contribution in the clinical record so a colleague can understand the decision. Keep prompts, screenshots or version logs in approved systems where local policy calls for them. GMC guidance on recording decisions, iatroX guide to documenting AI’s influence on a clinical decision.
What if I catch a dangerous error before anyone acts on it? Correct the output and protect the patient. The GMC says you must follow your workplace procedure for reporting adverse incidents and near misses, and should keep a record of the concern and your response. For an adverse incident involving a medical device, follow the relevant national reporting route as well. GMC guidance on raising a concern, GMC guidance on reporting medical device incidents.