A clinical note review checklist for AI-generated drafts

If the identity or encounter frame is wrong, stop and resolve it before editing details. Cosmetic corrections to a note attached to the wrong person do not reduce the underlying risk.

• Correct patient, encounter date, location, and type of visit.
• Correct author, participants, and information sources.
• Accurate reason for encounter and relevant consent documentation.
• No content from another patient, test, template example, or prior encounter.

AI-generated notes can compress a nuanced exchange into a stronger claim. Restore qualifiers such as “possible,” “reports,” “unclear,” or “pending” when they reflect the encounter. A concise record should not become a falsely certain record.

• Symptoms, duration, severity, and chronology match what was reported.
• Observed findings are distinguished from patient or collateral reports.
• Medication, allergy, dose, route, frequency, measurement, unit, date, and laterality are correct.
• Pertinent negatives appear only if they were actually assessed.
• Quotations are used only when the wording is accurate and relevant.

Compare the assessment and plan with the clinician's actual reasoning. Look for a missing alternative, an unsupported diagnosis, a plan that was discussed but rejected, or language that frames a patient unfairly. Consider whether the draft gives unequal weight to one speaker or omits a communication barrier.

• Does the assessment state uncertainty at the right level?
• Are important contradictions or limitations visible?
• Could a future reader distinguish facts, reports, and clinical interpretation?
• Is the language neutral, specific, and professionally appropriate?
• Would an omitted detail change care, follow-up, or interpretation?

• Every accepted action matches the encounter.
• The responsible person and timing are clear where required.
• Patient instructions, return precautions, referrals, tests, and monitoring are accurate.
• The note is understandable to another authorized clinician without unnecessary repetition.
• Corrections are complete before the user deliberately finalizes.