Insight Clinic is a Registered provider of Medicare, Northwest Melbourne Primary Care Network (NWMPCN), Care In Mind, and National Disability Insurance Scheme (NDIS).

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Use of AI-Assisted Tools for Clinical Notes and Documentation

Use of AI-Assisted Tools for Clinical Notes and Documentation

1. Purpose

The purpose of this policy is to outline the ethical, professional, and lawful use of Artificial Intelligence (AI)–assisted tools in the preparation of clinical notes, reports, correspondence, and administrative documentation. This policy ensures that the use of AI supports clinical efficiency while maintaining client safety, confidentiality, professional accountability, and compliance with relevant Australian legislation and professional standards.


2. Scope

This policy applies to all clinicians, contractors, students, and administrative staff engaged by Insight Clinic Mental Health Services who may use AI-assisted tools in connection with:

  • Clinical case notes
  • Assessment reports
  • Treatment plans
  • Letters (e.g., GP, school, NDIS, funding bodies)
  • Administrative or internal documentation

3. Definition of AI-Assisted Tools

AI-assisted tools refer to software or platforms that generate, rewrite, summarise, structure, or enhance text based on user input (e.g., drafting assistance, language refinement, or formatting support). These tools are used as an aid only and do not replace clinical judgment, assessment, or professional responsibility.


4. Guiding Principles

The use of AI-assisted tools must align with the following principles:

  • Client safety and wellbeing
  • Confidentiality and privacy
  • Professional accountability
  • Accuracy and integrity of clinical records
  • Compliance with ethical and legal obligations

5. Acceptable Use

AI-assisted tools may be used for the following purposes:

  • Structuring or re-phrasing clinician-written notes
  • Improving clarity, grammar, or professional tone
  • Drafting templates or generic clinical language
  • Assisting with formatting documentation to required standards
  • Supporting time efficiency in documentation

All AI-assisted outputs must be reviewed, edited, and approved by the treating clinician prior to finalisation or storage.


6. Prohibited Use

AI-assisted tools must not be used to:

  • Generate clinical opinions, diagnoses, formulations, or risk assessments independently
  • Replace direct clinical assessment or professional judgment
  • Make treatment recommendations without clinician oversight
  • Upload or input identifiable client information into unsecured or non-compliant platforms
  • Store, process, or analyse raw client data without appropriate safeguards

AI tools must never function as a decision-making authority in clinical care.


7. Confidentiality and Privacy

Clinicians must ensure that no identifiable client information (including names, dates of birth, addresses, Medicare details, or unique identifiers) is entered into AI tools unless the platform is explicitly compliant with Australian privacy standards.

  • All documentation must comply with the Privacy Act 1988 (Cth) and relevant health records legislation.
  • AI-assisted drafting must not compromise data security or confidentiality obligations.

8. Clinical Accountability

The treating clinician remains fully responsible for the accuracy, content, and clinical appropriateness of all notes and documents.

AI-generated content does not reduce or transfer professional liability.

Final documents must reflect the clinician’s own assessment, reasoning, and ethical obligations.


9. Transparency and Documentation

Where appropriate, the clinic may disclose that AI-assisted tools are used for documentation support only, not for clinical decision-making.

The use of AI does not alter informed consent requirements or client rights.


10. Training and Review

Staff are expected to use AI tools responsibly and in accordance with this policy.

This policy will be reviewed periodically to ensure alignment with evolving ethical standards, professional guidance, and legislative requirements.


11. Breach of Policy

Any misuse of AI-assisted tools that compromises client safety, confidentiality, or professional standards may result in corrective action in line with clinic governance procedures.


Policy Owner: Insight Clinic Mental Health Services
Review Cycle: Every 12 months or as required