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Rural Health Information Hub
Rural Health Information Hub

AI-Assisted Clinical Documentation

One of the most significant opportunities for AI in healthcare is reducing provider workloads by assisting with clinical documentation. Ambient clinical intelligence (that is, ambient listening, AI scribes) support clinical documentation in real time. AI scribes use microphones, speech recognition, natural language processing, and large language models to transcribe provider-patient conversations during a patient visit. Rural healthcare providers have described ambient listening technology as the entry point into AI-enabled workflows.

This technology offers benefits to rural healthcare organizations and providers such as improved face-to-face interactions between providers and patients, higher-quality clinical notes, and enhanced communication across care teams. In the telemedicine setting (see Telehealth Model), AI scribes are particularly important so the provider can connect with the patient rather than focusing on documentation. AI scribes can also enter information into the electronic health record, list possible diagnoses and codes, and give suggestions and actions the provider can take.

Examples of Rural Programs Using AI-Assisted Clinical Documentation

  • Patterson Health Center, a 16-bed Critical Access Hospital in Harper County, Kansas, uses an AI agent to help automate medical charting. The hospital's AI tool records, takes notes on, and summarizes patient visits for clinicians. Patterson gradually introduced AI to healthcare providers, making features optional and offering frequent demonstrations to foster acceptance. Additionally, providers can use the AI tool to dictate notes during convenient times (for example, during commutes). Documentation times have dropped from 20 to 12 minutes per patient and time spent in the emergency department per patient has decreased from 15 to 9 minutes. Providers estimate that AI tools have freed up 1-2 hours of their time per day.
  • Central Montana Medical Center, a 25-bed Critical Access Hospital serving a rural community in central Montana, uses ambient AI listening technology during clinical visits. To use the tool, healthcare providers place a mobile device in an exam room, disclose its use to patients, get their permission to use the technology, and conduct the medical visit. The AI tool captures clinically relevant information and generates structured notes in the patient's electronic health record.
  • White House Clinics, a network of Federally Qualified Healthcare Centers (FQHCs) serving patients in Kentucky, use AI scribe and voice technology to improve documentation completeness and ensure workflow consistency. These AI tools have helped address burnout, freeing up providers to have better work-life balance and reducing burden. Thoughtfully piloting the technology ensured organizational acceptance across clinicians, regardless of specialty or comfort level with technology.
  • Leaders at Ohio County Healthcare report that AI-assisted ambient listening helped clinicians reduce after-hours charting and allowed them to engage with patients rather than focus on screens. Framing AI tools as a supplement to human clinicians was key to fostering buy-in and adoption.
  • Ozarks Healthcare in West Plains, Missouri, is integrating an AI scribe to develop transcripts of patient-provider communications and prepare patient snapshots. The scribe can prepare transcripts in multiple languages.
  • Atrium Health is a nonprofit health system in Charlotte, North Carolina that serves rural areas in North Carolina, South Carolina, Georgia, and Alabama. Atrium is implementing an AI clinical documentation solution to create draft clinical summaries based on in-person exams and telehealth visits and enter them into electronic health records. This technology has helped Atrium healthcare providers to save up to 40 minutes per day, allowing them to see more patients.

Considerations for Implementation

AI-assisted clinical documentation tools are designed to support human providers, not replace them. Providers should obtain informed consent before using ambient listening tools or AI documentation tools and ensure patients understand how their information will be used. In practice, some providers address patient concerns by showing AI-generated notes or transcripts in real time during the visit and explaining that these tools allow them to spend more focused time with the patient.

The accuracy and consistency in performance of AI clinical documentation tools can vary. Reported issues include:

  • Hallucinations
  • Missed clinical details
  • Incorrect speaker attribution
  • Inaccuracy or misinterpretation in clinical notes

Ambient listening may be less accurate for patients who speak languages other than English or have regional accents. For these reasons, human review is a necessity, which may reduce some of the efficiencies offered by AI documentation.

Providers should understand the sources of data used to train AI systems. Algorithms that draw from non-clinically validated data, rather than evidence-based information, may introduce bias and reduce reliability of outputs. Providers should also understand how long the data, such as transcripts, are stored prior to deletion (for example, one week, two weeks, or longer) and where data are stored (for example, local servers, cloud environments, third-party systems), given implications for data privacy and security.

Resources to Learn More

What Hospital Leaders Are Learning from Real-World AI Use
Document
Summarizes a panel discussion about using AI to reduce burnout and administrative burden among healthcare providers in rural areas. Rural hospital leaders discuss the value of AI and how the healthcare systems are adopting technology, and offer advice for successful integration.
Organization(s): National Rural Health Association
Date: 1/2026