What I check before I sign an AI note

I like a draft. I do not trust one. The two can sit together if I leave myself two minutes and I look in the same places every time. When I “just skim,” I sign other people’s mistakes with better punctuation.

This is the pass I do because I have been burned.

Their words, not a cleaned-up version of their words

I search the note for the sentence that made the visit make sense. The med they stopped. The fight on Sunday. The “I gave my sister the bottle.” If that sentence has been smoothed into “patient reports recent interpersonal stress” I put the actual words back, or I do not sign.

A tool that keeps a verbatim line is doing me a favor. A tool that paraphrases the only line that mattered is doing me a harm I will not notice if I am late.

Meds: what I said I would do, what the note says I did

I look at the medication list and the plan as if I have never seen this patient. Dose, change, why. If I told them we would hold the increase until the TSH is back, and the plan says “increase as discussed,” I have created a different visit.

I also look for extras. Drafts sometimes keep a med I tapered off in June, or drop a PRN I mentioned once. I have signed both errors. The patient then lives in the error.

The exam I performed, not the exam the template wanted

If I did a short exam, the note stays short. I will not accept a full, balanced MSE I did not do, even if it is flattering. I already wrote about copy-forward. Same disease, new host.

If something was off, it has to be in the exam and in the assessment. An agitated person with an exam that says “calm, cooperative” is a note I cannot defend, and I should not need a reviewer to tell me that.

Necessity in this visit, not in the diagnosis list

I read the first problem, the assessment, and the plan out loud in my head. If I cannot hear why they needed me today, I write the sentence. “Still not sleeping, still missing work, last increase was 12 days ago, giving it time” is a reason. “MDD, continue meds” is a stamp.

Scoring a PHQ-9 does not finish this. The score has to agree with the story or I have to say why it does not.

Codes last, and only against the note I now believe

I used to pick the code and then hope the draft would dress for it. That is backwards and it is how you get a 99215 that reads like a refill. I finish the note. Then I ask what I actually did. Time, complexity, psychotherapy content that is really there.

If the code I wanted needs a sentence I do not have, I either add the sentence because it is true, or I pick a smaller code. I do not invent the sentence.

What I skip

I do not line-edit every transition. The note does not need to sound like a journal.

I do need my name to mean I was there, I looked, the dangerous parts are right, and I would still make this plan tomorrow morning.

Two minutes. Same places. Then sign. If I cannot spare the two minutes, I do not have time to see the next patient either. I just like pretending I do.