AI-Assisted Medical Documentation Policy

Private Psych MD

Effective Date: January 17, 2026

Private Psych MD utilizes artificial intelligence (AI) technology to assist with clinical documentation. This policy explains how we use AI in our practice, the safeguards we have in place, and your rights regarding AI-assisted documentation.

1. Overview of AI Documentation Technology

We use NextVisit AI, a HIPAA-compliant clinical documentation platform designed specifically for psychiatric practice. This technology assists our providers by transcribing and summarizing clinical encounters, allowing them to focus more fully on patient care during appointments.

2. How AI Documentation Works

During your appointment, with your consent, the AI system may record and transcribe the conversation between you and your provider. The AI then generates a draft clinical note summarizing the encounter. Your provider reviews, edits, and approves all AI-generated documentation before it becomes part of your official medical record. The AI does not make clinical decisions, diagnoses, or treatment recommendations.

3. Data Security and HIPAA Compliance

NextVisit AI is fully HIPAA-compliant and employs enterprise-grade security measures including: end-to-end encryption for all audio and text data; secure cloud infrastructure with SOC 2 compliance; strict access controls limiting data access to authorized personnel; automatic deletion of audio recordings after transcription processing; and Business Associate Agreements (BAAs) ensuring legal protection of your health information.

4. Provider Review and Oversight

All AI-generated documentation is reviewed and verified by your treating provider before being finalized. The AI serves as a documentation assistant only. Your provider maintains full responsibility for the accuracy and completeness of your medical record. Providers may edit, modify, or completely rewrite any AI-generated content.

5. What Information Is Captured

The AI documentation system may capture: verbal communication during your appointment; reported symptoms, concerns, and medical history discussed; treatment discussions and medication reviews; and clinical observations noted by your provider. The system does not capture information outside of your scheduled appointment time.

6. Data Retention and Storage

Audio recordings are processed and then deleted according to our data retention schedule. Transcriptions and clinical notes are retained as part of your medical record in accordance with New York State medical record retention requirements (minimum six years for adults, or three years after a minor reaches age 18). All data is stored on secure, encrypted servers within the United States.

7. Your Rights Regarding AI Documentation

You have the right to: be informed about our use of AI documentation technology; consent to or decline the use of AI during your appointments; request that AI documentation not be used for specific appointments; access your medical records including AI-assisted documentation; request amendments to your medical record; and withdraw consent for AI documentation at any time without affecting your care.

8. Opting Out

If you prefer not to have AI-assisted documentation used during your appointments, please inform your provider or our staff. Your decision will not affect the quality of care you receive. Alternative documentation methods will be used. You may change your preference at any time by notifying us.

9. Benefits of AI Documentation

AI-assisted documentation allows your provider to maintain better eye contact and engagement during appointments; creates more detailed and comprehensive clinical notes; reduces documentation time, allowing more focus on patient care; improves accuracy by capturing information discussed during the visit; and enables longitudinal tracking of symptoms and treatment progress over time.

10. Limitations of AI Technology

AI documentation technology has limitations. It may occasionally misinterpret or incorrectly transcribe speech. It does not understand context the way a human does. It cannot make clinical judgments or replace provider expertise. This is why all AI-generated content is reviewed and verified by your provider before becoming part of your official record.

11. Third-Party Access

Your AI-documented records are subject to the same privacy protections as all medical records. They will only be disclosed as permitted by HIPAA and New York State law: for treatment, payment, and healthcare operations; as required by law; or with your written authorization.

12. Updates to This Policy

We may update this policy as AI technology and regulations evolve. Material changes will be communicated to patients. The current version will always be available on our website and upon request.

13. Contact Information

If you have questions about our AI documentation practices or wish to discuss your preferences, please contact us at: contact@privatepsychmd.com or speak with your provider during your next appointment.