AI for Therapy Notes: What Helps and What to Avoid (HIPAA‑Aware)
Updated 2025-10-14
Practical guidance on using AI safely for note drafting and summaries without exposing PHI.
Where AI Helps
- Outlining common sections (subjective/objective skeletons).
- Rewriting sentences for clarity and professionalism.
- Creating patient‑friendly education summaries from therapist bullets.
What to Avoid
- Entering PHI into tools without a BAA or proper safeguards.
- Copy‑pasting generated text without clinical verification.
Safe Workflow Pattern
- Create de‑identified prompts/templates.
- Generate draft language offline or in approved tools.
- Clinically verify and add accurate patient specifics in your EMR.
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Frequently Asked Questions
Is AI documentation allowed?
Follow your organization policies. Use tools with a BAA when handling PHI.
Will this save time?
For many clinicians, AI helps with first drafts and phrasing, but clinical editing remains essential.