AI-Powered Dictation for Veterinary Records

After a visit to the veterinarian, the relevant details of the conversation should be recorded accurately in the medical record. AI dictation converts speech to text, which is then processed into a structured draft medical record. Vetz offers AI-based transcription and generation of medical records for veterinary clinics.

The completed medical record always requires review. The veterinarian in charge edits the draft and is responsible for its content before the medical record is finalized.

AI dictation or AI scribe—what's the difference?

These terms are often used interchangeably, but they describe two different approaches.

With AI dictation, the veterinarian records their notes themselves, either during or after the visit. The veterinarian chooses what to say and in what order, and the AI converts the dictation into structured medical record text. The process is similar to traditional dictation, but without the need for anyone to transcribe the text afterward.

An AI scribe, on the other hand, listens to the entire consultation—that is, the conversation between the veterinarian and the pet owner. Based on that conversation, the AI generates a draft medical record without the veterinarian having to dictate anything separately. Learn more about this approach in “What Is an AI Scribe?”.

Dictation is often useful when the veterinarian wants to write the notes themselves—for example, after a visit where a lot happened without being said out loud, or when the conversation isn’t suitable for recording. An AI scribe is useful when the veterinarian wants to be able to focus entirely on the animal and the pet owner during the visit. In Vetz, you can use both methods: Vetz can listen in during the conversation with the pet owner, and the veterinarian can also dictate the medical record instead of typing it.

Transcription, Medical Record Documentation, and Decision Support

Transcription converts speech into continuous text. The result is usually close to what was said and does not follow the clinic’s medical record format.

In structured medical record-keeping, relevant information is organized under the headings in the medical record. Such a draft should reflect the content of the consultation and provide the veterinarian with an editable template for maintaining the medical record.

Clinical decision support has a different area of application. Such features provide support for medical decisions, such as suggestions for differential diagnoses. A generated draft medical record should be treated as a basis for writing the medical record. The professional assessment is always made by the veterinarian in charge.

This is what the workflow looks like in Vetz

Vetz can be used in a web browser or as an app on iPhone and Android. All you need is a device with a microphone. The workflow consists of five steps, from recording to the finished medical record.

When the conversation with the pet owner begins, the veterinarian activates Vetz, which starts listening in accordance with the clinic’s established routine.
Vetz transcribes the conversation as it takes place and uses the clinic's templates to create a draft medical record, which is ready shortly after the conversation ends.
The user reads through the draft and compares it with their recollection and any notes they may have taken.
Mishearings are corrected and missing information is added, either manually or with the help of AI.
The veterinarian approves the text and is responsible for its content before the medical record is finalized.

Vetz also works during video and phone consultations and supports dictation in more than ten languages.

Content that may need to be included in the draft medical record

The format of the medical record varies by clinic and type of visit. A draft may need to include the following sections.

The medical history summarizes the relevant information that emerged during the interview.
Clinical findings are reported based on the information provided or recorded by the veterinarian.
The assessment must reflect the veterinarian's documented professional judgment.
Measures that have been implemented must be described in accordance with the content of the consultation.
The plan should correspond to what the veterinarian decided and communicated during the visit.

The AI draft can only be based on information that has been captured and processed. Information that was never spoken or recorded may therefore need to be added manually. This is also where AI dictation can complement an AI scribe: findings that the veterinarian noted silently during the examination can be dictated afterward.

In Vetz, clinics can use their own medical record templates, ensuring that drafts follow the clinic’s procedures and are consistent. Vetz helps clinics set up templates that suit different workflows.

Review of Incorrect Interpretations and Missing Information

Automatically generated text may contain mishearings or omissions. The review should be conducted before the medical record is finalized, while the veterinarian still has the consultation fresh in mind.

The following checks may be part of the clinic's routine.

If there are multiple people speaking in the recording, make sure the information has been linked to the correct speaker.
Please read the name and identification information very carefully before approving it.
Verify the figures against available source material and your own notes.
Look for omitted negations that could change the meaning of the medical record text.
Ensure that the medical history, clinical findings, assessment, interventions, and plan have been accurately documented.
Remove any text that is not supported by the consultation or has been placed under the wrong heading.

All detected errors must be corrected during the veterinarian’s review. The AI draft does not replace the veterinarian’s professional responsibility for verification and should not be finalized without a thorough review. Additional common checkpoints are described in “AI Record-Keeping for Veterinarians.”

Use in conjunction with the clinic's medical records system

The draft medical record must fit into the clinic’s existing medical record workflow. The clinic should therefore clarify where the text is reviewed, how it is transferred, and in which system the final medical record is approved.

Vetz integrates with medical record systems via the systems’ APIs or their export and import functions. Once the integration is active, the approved note can be transferred to the medical record system with the click of a button, without the need for manual copying. Vetz supports most major medical record systems. Clinics whose systems are not yet supported can contact Vetz to find out what is required for integration.

During a pilot, the clinic should test the entire process, from recording to the final medical record. The test must cover both normal use and situations where the transmission is interrupted or requires manual intervention. Read more in “How Vetz Works.”

Consent, Personal Information, and Data Processing

A recorded conversation may contain personal information about the pet owner and other individuals. It may also contain customer information and information related to medical records. The clinic therefore needs to review how this information is handled before implementing the service.

Vetz recommends informing the pet owner that AI is used to assist with record-keeping and can provide a pre-written template. Integration with the medical record system is encrypted and compliant with the GDPR.

The clinic should have written answers to the following questions before implementation.

How should the pet owner be informed about the recording, and when is consent required?
How should the clinic document that information has been provided or consent has been obtained?
What personal data and customer information is processed during the workflow?
Where are the audio files and the generated draft log stored?
How long is the data retained, and how is it deleted?
Which users can access the system, and how are their permissions managed?
Are subcontractors used for data processing, and where does the processing take place?
How are requests from data subjects and any security incidents handled?

Questions regarding storage, access, and subcontractors should be directed to Vetz prior to signing a contract. The clinic’s data protection officer should then evaluate the responses based on the organization’s own procedures.

Introduce AI dictation through a limited pilot program

A test group may consist of veterinarians who create the draft medical records and a clinic manager who monitors the workflow. The group should use the tool in a limited selection of consultations before the clinic decides on broader implementation.

Determine which types of visits will be included and how long the pilot program will last.
Measure the time spent on record-keeping prior to implementation according to a common definition.
Measure the corresponding time using AI dictation for comparable types of visits.
Keep track of how many drafts require major corrections or manual additions.
Evaluate the quality of the medical records and how the data transfer to the medical records system works.

The results need to be evaluated based on the clinic’s own workflows. Time savings should not be assumed until the clinic has compared workflows under similar conditions. For more information on where time can be saved, see “Save Time with AI for Veterinarians.”

When manual journal entries or additional verification are needed

AI-powered dictation is not suitable for every situation without backup procedures. Continued manual record-keeping or additional verification may be necessary in the following cases.

Recording could not be started or was interrupted during the consultation.
The issue of information and consent was not handled in accordance with the clinic's procedures.
The sound quality makes parts of the conversation difficult to understand.
Important information was provided before or after the recorded portion of the visit.
The draft journal entry contains ambiguities that cannot be verified against the available documentation.
The transfer to the medical records system is not working according to the planned procedure.

The clinic should have a documented contingency plan for these situations. The veterinarian determines when the draft can be corrected and when the medical record entry needs to be written by hand.

Learn more about Vetz

An overview of the product is available on the page about Vetz's features. Clinicians who would like to try AI dictation in their own workflow can schedule a demonstration.