AI-Powered Record-Keeping for Veterinarians

During a consultation, Vetz.ai can transcribe the conversation and generate a draft medical record. The veterinarian is always responsible for the final medical record. Before signing, the veterinarian must review the draft and correct any content that is incorrect, unclear, or incomplete.

AI support can provide a basis for writing medical records, but the records must still reflect what actually came up during the consultation and what information the veterinarian has deemed relevant. Learn more about this approach in “What is AI Scribe?”.

Here's what the workflow might look like

The clinic must first decide when audio recordings may be used and how the pet owner should be informed. During the consultation, Vetz.ai is used for transcription. Once the consultation is over, a structured draft medical record is created, which the veterinarian reviews.

The veterinarian compares the draft with the consultation, corrects any information as needed, and completes the medical record before signing it. The medical record is not finalized until after this review and signature by the veterinarian in charge.

An up-to-date overview of the product is available on Vetz.ai's features page.

Data Requiring Special Verification

First, verify the patient's identity and ownership information. This information must match the correct animal and the correct case before the medical record is signed.

Next, review the medical history and physical examination findings to ensure they match what was actually said and observed during the consultation. Verify that the assessment reflects the veterinarian’s own judgment and that each listed action is accurately described.

If the draft mentions medications, the veterinarian must verify the medication and dosage. Follow-ups, return visits, or other follow-up instructions must also be reviewed before they are included in the medical record.

A transcribed conversation may contain slips of the tongue, unclear speech, or phrases that lack context. An AI-generated draft may therefore contain incorrect or fabricated phrases. The user must correct these in the draft medical record and follow the clinic’s protocol if uncertainty remains.

The most common mistakes in medical record writing and how AI can help you avoid them outline common checkpoints when working on draft medical records.

Questions for a Danish clinic prior to implementation

The clinic needs to clarify its legal basis for sound therapy and develop guidelines for how the tool may be used. The pet owner needs to receive information tailored to the clinic’s chosen process and the processing of personal data that takes place.

Access to audio recordings and draft medical records should be restricted to authorized personnel. The clinic also needs to determine how long the material is stored and who is responsible for monitoring access permissions.

The data processor agreement, data hosting arrangements, and incident response procedures must be clarified before the start of operations. This also includes how the clinic should respond if the wrong person gains access or if data is handled in a manner that deviates from the clinic’s instructions.

Current Danish requirements regarding sound therapy, personal data, and record-keeping should be verified against relevant Danish government sources as well as the clinic’s own legal and data protection advisors. These requirements may depend on the clinic’s systems, agreements, and treatment methods.

Test the approach in a pilot project

A pilot study may include types of consultations that reflect the clinic’s routine practice. Veterinarians should use documented review criteria for each draft medical record to ensure that the same information is consistently checked throughout the test.

The clinic can track which corrections are needed and how long the review takes. The data shows where the drafts require the most attention and whether the workflow is effective for the team.

Also, establish a procedure for situations in which AI support should not be used. This may include calls with poor audio quality, interruptions during the consultation, or situations where the content is deemed particularly sensitive.

Clear Roles During the Consultation

The clinic needs to determine who launches the tool and when that happens. It should also be clear which veterinarian reviews and signs the draft medical record associated with the consultation.

Staff who use the tool need training on how to handle audio recordings, how to review drafts, and what to do in the event of interruptions. If speech is unclear, the user must ensure that the medical record reflects the correct information, rather than relying on the transcription.

Sensitive conversations require a predetermined procedure. For example, the clinic may decide to pause the tool in certain situations or to handle the material in accordance with specific access rules.

Confidentiality, Errors, and Clinical Monitoring

Confidentiality is based on restricted access to the material and the clinic having documented instructions for its use. Access privileges should be reviewed when staff members change roles or leave the clinic.

Errors in a draft must be corrected by the responsible veterinarian before signing. The clinic should have a documented procedure for how errors are detected, corrected, and followed up on when the same type of error recurs.

The veterinarian retains clinical oversight through review and signature. The AI tool can generate a draft, while the veterinarian determines what should be included in the medical record and is responsible for its content.

Sources to Review During the Evaluation

The Danish article “Remember the Rules for Medical Record-Keeping When Using AI” should be read in its entirety before the clinic uses it as a reference. It is published by Fysio.dk and concerns medical record-keeping with AI in physical therapy, which means that the clinic needs to assess how the arguments apply to veterinary practice and the Danish requirements that apply to its own operations.

The article “Artificial Intelligence as a Medical Recorder: A Trojan Horse” has been published as an opinion piece in *Ugeskrift for Læger*. An opinion piece can raise questions worth exploring, but the clinic should distinguish between the author’s views and the applicable requirements set by regulatory authorities or the terms of its own agreements.

Clinics that would like to evaluate Vetz.ai within their own workflow can schedule a demonstration.