AI client notes for psychologists ?

AI for clinical note taking

This blog is a public service, as I must have discussed this issue with more than a dozen supervisees or practice owners in the past month alone.  So in this instance, rather than paying for a consult, please feel free to read the following for free.

Large language model AI exploded into all of our awareness at the end of 2022 with Chat GPT, and since then anyone who is anyone has to have an AI assistant.  Chat GPT is probably the market leader currently, with Microsoft co-pilot and Google Gemini not far behind.  Meanwhile, other smaller companies have been carving out very specific use cases for AI and developing products that fill a niche.

Client progress notes are currently capturing everyone’s imagination.  Essentially, you turn your laptop on at the start of the session, the AI “listens” and then spits out a well formatted and sensible summary of the session at the end.

Before I tell you why im against it, let me acknowledge that a lot of people are passionate advocates.  With that in mind, let me at least raise a few safety principles because most people are going to ignore my advice anyway.

Transparency and Privacy

If you are going to use one of these apps, please make sure that you are explicit about what you are using, and why and what happens with the data in your consent form.  For now, the technology is new enough that I would suggest that its prudent to actually briefly discuss it with all your clients verbally as well.  

Technical aspects

Many people are worried about the technical aspects of privacy; are they sharing their client data with skynet in some dystopian nightmare future.  While I will not give legal advice and you should consult your own indemnity lawyer, the major commercially available products state that they use the data safely.  Effectively your little AI bot lives in a walled garden in the cloud that belongs to you, and it never leaves that walled garden or communicates back to the mothership.  However, with this in mind I would point out that setting up safe multi-instance implementations of software is not easy.  I trust serious programmers to do it, I don’t trust psychologists who are “training their own” AI bots to do things.  As with most things, please pay for the real version rather than trying to get away with the freebie

Transcript function

Some AI note taking bots produce a verbatim transcript of the entire session.  Please dont be the person who chooses to save that in your client notes.  Client notes are a product, transcripts are an ingredient in producing that product.  Delete these as soon as possible.  When you get subpoenaed (and you will) you will have to hand over ALL notes in your possession or face a contempt of court finding.  Scratch notes, audio and video recordings, and transcripts of sessions belong no where near a clients file and should always be deleted as quickly as practicable.

If you are careful about the above considerations, I think you can safely implement any of the commercial progress note apps.  So why am I against them anyway ?

Two reasons really, the notes produced are worse than my notes, and they take longer to produce.

When you sit down and press the magic button to turn the past hour into a progress note and the computer spits it back to you in less than a second it feels like magic.  But Id like you to look past the magic and ask about quality.

• Does the note have information in there you would not like the client to read if they accessed the note ?
• Does the note have information in there you would not like an insurance assessor to read if the client is applying for life insurance ?
• Does the note hae information in there you would not like the clients partner to read when they separate and their lawyer subpoenas your file to prove that they are an unfit parent ?
• Does the note have information in there you would not like a claims adjustor to read if your client dies and the insurance company wants to weasel out of paying out their life insurance ?

Good clinical notes are not a comprehensive transcript of what happened in session.  They are are carefully balanced set of facial statements, descriptions and memory prompts designed to give you enough information to carry on therapy.  They do not include everything that is mentioned, and many things are omitted.

Each implementation of note taking AIs that I have seen are not fit for purpose in terms of striking this balance. I spend a lot of time editing them to be exactly what I am happy to put my name to.  I suspect they could be trained to give me the notes that I want, but who has that kind of time ?

Which brings me to my second point.  If your progress notes are so onerous that you need an AI to do them, I suspect you haven’t learned how to do them efficiently.  I timed myself recently, and for a session that is not a first session, I average 90 seconds.  I spend way more time than that editing badly written AI notes.

Learn to use templates, learn to avoid superfluous clinical narrative, and develop a good workflow.  I worry that outsourcing these tasks to AI at this stage is a false economy.  Not only is it not the time saver you think it is, your time responding to subpoena, cross examination, and coroners in future will well and truly offset any gains.

If you want a starting point, the note-taking template we used at Benchmark is available through PREP, with notes on adapting it to your setting.