As technology becomes increasingly embedded in clinical workflows, many health care clinicians are turning to artificial intelligence (AI) tools to help lighten the charting load. One of the most buzzed-about tools is ChatGPT, an artificial intelligence chatbot that seems like it can do everything from planning your next vacation to California, analyzing the best applications for a job, to writing your History of Present Illness (HPI) for a diabetic patient.
Before you start relying on ChatGPT for clinical documentation, it is important to understand what it is, how it works, and the risks that come with using a general-purpose AI tool in a health care setting. This article breaks down the benefits and limitations of using ChatGPT in clinical documentation, and introduces a better, health care-focused solution: an AI medical scribe.
What is ChatGPT?
If you are a human reading this, then you have heard about ChatGPT. For those that are not human, ChatGPT is a language-based artificial intelligence model developed by OpenAI. It is designed to generate human-like responses to questions and prompts in a conversational format. You can ask it for almost anything, from drafting emails to summarizing long documents, and even helping with parts of your clinical notes.
Here is what clinicians should remember: ChatGPT is a general-purpose tool. It was trained on vast amounts of publicly available internet data, books, and articles, but it was not built specifically for health care or medical documentation. That distinction matters greatly when clinicians are dealing with patient care and legal documentation.
The potential benefits of ChatGPT in clinical documentation
Even though ChatGPT was not created for health care, some clinicians are experimenting with ways to use it in daily charting tasks. Possible upsides include:
1. Quickly generate HPI questions. If you are stuck trying to remember all the review of systems (ROS) or pertinent HPI elements for a patient presenting with abdominal pain, you can prompt ChatGPT with a question such as: “What are some helpful questions to ask during an HPI for abdominal pain?” Within seconds, you might get a list that includes onset, duration, location, radiation, character, aggravating and relieving factors, associated symptoms, and more. It can be a quick way to jog your memory.
2. Create a comprehensive neurological exam template. Need to document a full neuro exam but do not want to type it from scratch? Ask ChatGPT to generate a neuro exam template, and it can return a section including mental status, cranial nerves, motor strength, reflexes, coordination, and gait. Make sure to check for accuracy!
3. Help with procedure documentation (i.e., laceration repair). If you need a refresher on how to write a complete procedure note for a laceration repair, you can ask ChatGPT: “How do I document a 3 cm laceration repair with sutures?” It might return a structured note with fields like location, length, depth, anesthesia used, type of suture, number of sutures, and patient tolerance of the procedure.
4. Draft general discharge instructions. You can use ChatGPT to draft generic discharge instructions, such as: “Create discharge instructions for a diabetic patient with hypoglycemia.” This could provide a starting point for education on symptoms to watch for, when to return, medication adjustments, and dietary recommendations.
These use cases can save time, especially when you are mentally exhausted or trying to avoid charting at home after hours. However, before fully embracing ChatGPT for charting, you need to be aware of the serious limitations.
The risks and limitations of using ChatGPT for clinical documentation
While it is tempting to use ChatGPT to lighten your charting workload, there are serious concerns to consider, especially regarding patient safety, accuracy, and compliance.
1. Not evidence-based or always accurate. ChatGPT generates responses based on patterns in its training data. It does not “know” medicine, cannot verify clinical guidelines, and cannot guarantee that its responses are accurate or evidence-based. This may lead to misinformation or outdated practices being included in your notes.
2. Not specialized in health care. Unlike medical-specific software, ChatGPT does not always understand medical terminology or documentation standards. Spelling errors, incorrect acronyms, or unusual phrasing in chart notes can have serious legal implications. It also is not designed to follow clinical workflows such as SOAP note format or meet EHR requirements.
3. Not HIPAA compliant. This is critical. ChatGPT is not HIPAA compliant, so you should never enter any protected health information (PHI) into the tool. Doing so could create legal risk. Even de-identified information can be risky if not handled carefully.
4. No integration with EHRs. Because ChatGPT is not integrated with your EHR, any content it generates must be manually reviewed, edited, and copied into the chart. This still takes time and increases the potential for errors.
5. Cannot replace clinical judgment. AI can be helpful, but it is not a licensed provider. Overreliance on ChatGPT can lead to overconfidence in AI-generated content, affecting care quality and documentation integrity.
6. Consistency of information. ChatGPT is only as good as the information provided to it. The more specific the questions, the better the results. Accuracy can improve with follow-up questions and feedback, but this feature is only available on the paid plan.
A better solution: Use an AI medical scribe
If your goal is to save time on charting without compromising accuracy, compliance, or patient safety, a better option is a health care-specific AI tool, such as an AI medical scribe.
What is an AI medical scribe?
An AI medical scribe listens to patient encounters in real time and generates accurate, EHR-ready notes based on what was said. Unlike ChatGPT, these tools are built specifically for health care, with HIPAA compliance, accurate medical terminology, and evidence-based templates.
Key benefits of an AI medical scribe:
1. Real-time documentation. No more typing during visits or trying to recall everything after hours.
2. EHR integration. Notes can be seamlessly uploaded or synced into the patient’s chart.
3. HIPAA-compliant. Built to meet strict privacy and security regulations.
4. Tailored to health care. Templates, terminology, and workflows fit your specialty.
5. Saves hours each week. Clinicians report saving more than two hours daily by offloading charting tasks, improving work-life balance.
Using an AI medical scribe helps you stay present with patients, reduces the mental load of documentation, and gives you back your evenings and weekends.
Final thoughts: Use ChatGPT wisely, but choose tools built for health care
ChatGPT can be helpful for brainstorming, refreshing your memory, or creating templates, but it is not designed to meet the clinical, legal, and ethical demands of patient documentation. And ChatGPT is not HIPAA compliant.
If you are a health care provider who is constantly behind on charts, tempted to bring work home, and missing out on personal life, know this: There is a better way. Health care-specific AI tools, such as AI medical scribes, can remove the burden of documentation so you can focus on what you do best: caring for your patients.
Erica D, the NP Charting Coach, is a family nurse practitioner and the creator of The Nurse Practitioner Charting School. She specializes in helping overwhelmed nurse practitioners improve their charting skills, enabling them to achieve a better work-life balance and finally stop charting at home! She can also be reached on YouTube and Instagram.
Erica has partnered with Freed, an AI medical scribe. After incorporating Freed into her own practice, Erica was impressed by the technology’s accuracy and its ability to save clinicians significant time on charting. Learn more about Freed here: https://getfreed.sjv.io/m5kY2M, and feel free to use the affiliate code NPCHARTING for $50 off your first month!
