§ 01 / Glossary
Glossary.
Canonical definitions of AI medical scribe terminology.
AI scribe
Software that generates a clinical note from a patient encounter, either ambiently or from dictation.
Ambient consent
Patient notification and agreement to being AI-scribed during a visit.
Ambient scribe
An AI scribe that listens to a visit in real time and produces a note automatically.
APSO note
SOAP inverted so Assessment and Plan appear first.
ASR (automatic speech recognition)
The technology that turns spoken audio into text.
Audit log
A tamper-resistant record of who accessed what PHI, when.
Chief complaint
The patient's stated reason for the visit, in their own words where possible.
Clinical decision support (CDS)
Software prompts that inform, but do not make, a clinical decision.
Clinical documentation
The written record of a patient encounter.
Clinical NLP
Natural language processing tuned to clinical text.
Clinician attestation
The clinician's signed acknowledgment that an AI-generated note is accurate.
Clinician burnout
Chronic emotional and physical exhaustion associated with clinical work.
Cloud hosting
Where the vendor runs its infrastructure.
CPT coding
The procedure-code system used to bill US visits.
DAP note
Data, Assessment, Plan — the dominant format in mental-health documentation.
Data residency
The country or region where PHI is physically stored.
Data retention
How long a vendor keeps audio, transcripts, and generated notes.
De-identification (Safe Harbor)
Removing 18 HIPAA identifiers so a record is no longer PHI.
Dictation
Speaking a note aloud for transcription, rather than ambient capture.
Differential diagnosis
The ranked list of possible diagnoses the clinician is weighing.
E/M coding
Evaluation-and-Management billing levels for outpatient visits.
EHR / EMR
Electronic Health Record — the software of record for a patient chart.
Encounter
One patient visit with a clinician.
Encryption at rest
Protection of stored PHI on disk.
Encryption in transit
Protection of PHI as it moves over a network.
FDA Software as a Medical Device (SaMD)
Regulatory category for software that itself is a medical device.
FHIR
The modern healthcare data-exchange standard.
GDPR
The EU regulation governing personal-data processing.
Hallucination
Fabricated content in an AI-generated note that was not in the encounter.
HIPAA
US federal law that governs Protected Health Information.
HIPAA BAA
A Business Associate Agreement that legally binds a vendor to HIPAA rules.
HIPAA Privacy Rule
The HIPAA subpart that governs use and disclosure of PHI.
HIPAA Security Rule
The HIPAA subpart that requires administrative, physical, and technical safeguards for ePHI.
HITECH Act
US law that strengthened HIPAA enforcement and breach-notification rules.
HITRUST CSF
A prescriptive security framework common in US healthcare.
HL7 v2
The older healthcare messaging standard, still ubiquitous.
HPI (History of Present Illness)
The narrative of the current problem's onset, course, and character.
ICD-10
The billing diagnosis code system used by US clinicians.
LLM (large language model)
The AI model that turns transcript into a structured note.
LOINC
The universal code system for lab tests and clinical observations.
Minimum-necessary standard
HIPAA requirement to use or disclose only the PHI needed for the task.
MSE (Mental Status Exam)
A structured psychiatric exam covering appearance, mood, cognition, and insight.
Note bloat
Over-inclusion of boilerplate and irrelevant content in a clinical note.
Note template
A reusable structure that shapes how the AI scribe formats its output.
On-device vs cloud
Where transcription and note generation happen.
ONC Health IT Certification
Federal certification program for health-IT that connects to certified EHRs.
Pajama time
Documentation work clinicians do at home after clinic hours.
PHI
Protected Health Information — health data that HIPAA protects.
PIPEDA
Canadian federal privacy law covering personal information.
Prior authorization
Insurer approval required before a service is delivered.
ROI for AI scribes
The economic case for adopting an ambient AI scribe.
ROS (Review of Systems)
A systems-based checklist of patient-reported symptoms.
RxNorm
A normalized vocabulary for clinical drugs used in US EHRs.
SMART on FHIR
An open standard that lets third-party apps read and write to an EHR.
SNOMED CT
A comprehensive clinical terminology for diagnoses, findings, and procedures.
SOAP note
A four-part clinical note: Subjective, Objective, Assessment, Plan.
SOC 2
An attestation on a vendor's security controls.
Speaker diarization
Identifying who spoke which line in a multi-speaker transcript.
Structured vs narrative note
Whether note content is in discrete fields or free prose.
Sub-processor
A third-party vendor a business associate uses to help handle PHI.
TEFCA
Federal framework for nationwide health-data exchange.
Training-data use
Whether a vendor reuses clinic data to improve its models.
Two-party consent
State-law requirement that everyone in a conversation consents to being recorded.
Zero-retention mode
A vendor configuration that discards audio (and sometimes transcripts) immediately after note generation.