1. Governance and Oversight

1. The AI Oversight Officer named above is responsible for this policy, for approving any AI tool that touches patient information, for the annual review, and for receiving incident reports. The oversight group brings clinical, legal, IT and patient-safety perspectives; in a small practice those are the physician-owner, the office manager and outside counsel, and that is acceptable.
2. No "shadow AI". Staff and clinicians use only AI tools that the Oversight Officer has approved and that operate under a signed Business Associate Agreement. Patient information is never entered into a consumer chatbot, a personal AI app, or any tool without a BAA. PodScribe is the practice's approved ambient scribe.
3. This policy addresses the consent workflow, opt-out handling, retention and deletion, clinician review responsibilities, continuity, monitoring, training and incident reporting. It is reviewed at least annually and whenever state law, the vendor's terms, or regulatory guidance changes.

2. Vendor Due Diligence: How PodScribe Handles Our Data

The practice has reviewed the following, which PodScribe publishes at podiatry-scribe.com/hipaa and podiatry-scribe.com/privacy. The Oversight Officer re-confirms them at each annual review.

• Business Associate Agreement. PodScribe LLC signs a BAA with the practice (downloadable from PodScribe Settings). PodScribe's own processors, Microsoft Azure Speech and Azure OpenAI, operate under BAAs with PodScribe.
• Where data is processed. US-based Azure data centers only. Encrypted with AES-256 at rest and TLS 1.2+ in transit.
• Minimum necessary. Patient identifiers (name, date of birth, SSN, phone, email, address, insurance and account numbers, MRN) are replaced with placeholders before any text reaches the AI, and the call is refused rather than sent if that step fails.
• Never used for training. Our transcripts and notes are never used to train or improve any AI model, and the AI services retain nothing after processing.
• Audio is never stored. The recording is used only to produce the transcript and is discarded immediately. There is no audio retention window to manage.
• Transcript retention is the practice's choice (section 5). The transcript is working material and is never part of the chart or of any record export.
• Only the signed note is the record. Every note is reviewed and edited by the clinician and signed one note at a time behind a written attestation. There is no automatic or batch signing. Signed notes are locked; corrections are made by addendum.
• Audit logging. Every access to patient information, every note signature, and every deletion or retention purge is audit-logged by PodScribe.
• Local validation. Before relying on the scribe, and again after any major change, the practice runs a validation period: for at least notes, the clinician compares the AI draft with the signed note and with what actually happened at the visit, and the Oversight Officer records the result. Vendor accuracy claims are not a substitute for this.

3. Disclosure and Informed Consent

1. Written disclosure and consent at intake. Every patient receives the written disclosure and consent (PodScribe's patient consent form at podiatry-scribe.com/patient-consent, or the recording-consent question in the practice's electronic intake). It explains what is recorded, that audio is not kept, where processing happens and under what protections, that the clinician reviews and edits the draft before signing, that the audio, transcript and AI draft are not the official medical record, how the transcript is retained, and the alternative if the patient declines. A signed copy is kept in the chart.
2. Verbal disclosure at every visit, before recording starts. The clinician tells everyone in the room that an AI scribe will be used, and asks, before the recording is started. This applies to family members, caregivers and interpreters as well as the patient. The script in the box below is used, in the clinician's own words.
3. All-party consent. Where state law requires it (Florida does), consent is obtained from every person whose voice will be recorded, verbally at each visit or in writing at intake with a clear opt-out. Anyone present may ask that recording stop at any time, and it stops.
4. Opt-outs are honored without penalty. A patient who declines is seen, examined and treated exactly as any other patient. The clinician documents the visit another way (section 7). In PodScribe the decline is recorded and the chart carries a "do not record" flag that also appears on the visit, so the clinician sees it at the moment they would press record.
5. The decision is documented. The consent answer is recorded in the chart (the intake writes it; a paper form is scanned in). When the practice enables it, PodScribe prints the patient's recording decision under the note signature. A patient may change their answer at any time by telling the office, and the change is documented the same way.

4. Legal Medical Record Status

Ambient scribing can create several artifacts -- the audio, the transcript, the AI draft, and the signed note -- and they can differ. To remove any ambiguity, the practice adopts the following positions and communicates them to patients through the consent disclosure:

1. The audio recording is not part of the designated record set or the legal medical record. PodScribe never stores it.
2. The transcript is not part of the legal medical record. It is working material from which the note is produced, and it is excluded from record exports and releases.
3. The AI-generated draft is not the legal medical record.
4. Only the clinician-reviewed, edited and signed note in the chart is the official medical record of the visit.
5. Requests for records are handled by the practice as the covered entity. PodScribe, as our Business Associate, refers any request it receives to the practice and acts only on the practice's direction or as the law requires.

5. Retention and Deletion

1. Audio: discarded immediately after transcription. Zero retention. Nothing exists for a patient to ask us to delete.
2. Transcript: the practice has chosen the following PodScribe setting (Settings, Data Retention, Visit transcripts) and discloses it on the patient consent form:
   Do not store the transcript. It is removed the moment the note is generated; the note cannot be regenerated afterward. Store the transcript with the note for the practice's note-retention window of , so the note can be regenerated while it is being reviewed.

   Risk-management guidance recommends deleting the draft transcript once the clinician signs the note. Of the two settings available today, "Do not store" is the closer match. Which setting is right for this practice was decided with counsel and the malpractice carrier on .

3. Recovery copies. PodScribe keeps a server-side copy of each transcription so a visit is not lost if a device fails before the transcript arrives. Those copies follow the practice's transcript setting and note-retention window and are deleted on the same schedule; they are not part of the chart.
4. Signed notes are retained under the practice's medical-records retention schedule: . (Practices that copy the signed note into another EHR keep it there; PodScribe's copy expires on the window set in PodScribe Settings.)
5. Patient deletion requests. A patient who asks that the transcript of a visit be deleted is answered by the Oversight Officer within business days. The request, the action taken and the confirmation are logged in the practice's request log. If audio is requested, the patient is told none exists.
6. Verifiable deletion. PodScribe deletes from its live database automatically when a transcript is purged or a retention window ends and writes an audit entry for each purge and each cleanup run. Encrypted platform backups age out on the vendor's published schedule and are used only for disaster recovery, never as a records source. The Oversight Officer reviews deletion activity with PodScribe at least annually.

6. Clinician Review, Data Integrity and Signing

The most important safeguard in the whole workflow is the clinician's final review. An AI draft can omit, overgeneralize, mis-hear, or invent. Before signing, the clinician confirms the note is accurate, complete, internally consistent and reflects the care actually provided.

1. No auto-sign, no batch signing. Each note is signed individually, from the note itself, after review. PodScribe offers no bulk or automatic signing and the practice does not create any workflow that bypasses review. Signed notes are locked; corrections are append-only addenda.
2. Attestation. Signing in PodScribe makes this attestation: "I attest that I have reviewed this AI-assisted documentation in its entirety, that it accurately reflects the history, examination, and services I personally performed during this encounter, and that I have corrected any inaccuracies. This is my documentation and I take professional responsibility for its content."
3. Heightened review is applied to complex multi-problem visits, patients with limited English proficiency, behavioral-health discussions, pediatric visits, masked encounters, visits in noisy rooms, and informed-consent discussions for procedures.
4. Automation bias. Clinicians do not over-trust the draft. Accepting a note without reading it is a policy violation, and the practice audits for it (section 8).

7. Continuity Plan (scribe unavailable, or patient declines)

1. If PodScribe is unavailable, performs poorly, or the patient (or anyone present) declines recording, the clinician documents the visit by typing or dictating into PodScribe's Note Generator without a recording, by the template builders, by a handwritten or typed note entered afterward, or directly in the practice's EHR. Care is never delayed for the tool.
2. During an outage no patient information is entered into any non-approved tool (section 1).
3. The Oversight Officer decides when the scribe is returned to routine use after an outage or a performance concern, and records the decision.

8. Ongoing Monitoring, Quality Oversight and Incident Reporting

1. Note-accuracy audit. Every , the Oversight Officer or a designee reviews a random sample of signed notes per clinician against the clinician's recollection, the chart and (where kept) the transcript, and records error types found. PodScribe's Compliance tab may be used as part of the review.
2. Automation-bias check. The same audit notes how often drafts were signed with no edits, and the clinician is asked about them.
3. Quality indicators. Patient complaints about recording, opt-outs and consent refusals are counted and reviewed at each audit.
4. Incident reporting. The following are reported to the Oversight Officer within one business day: a note signed with a wrong-patient, wrong-side or invented finding; a recording made over a documented decline or without disclosure; a privacy complaint about the scribe; any suspected unauthorized access. Platform incidents are also reported to PodScribe at support@podiatry-scribe.com. The officer records the incident, the correction (addendum, patient notification where required, staff retraining) and the outcome.

9. Training

All clinicians and staff are trained at hire and at least annually on: the disclosure script and written consent; honoring and documenting opt-outs; the clinician review checklist and attestation; the legal-record positions in section 4; retention and deletion requests; the continuity plan; and incident reporting.

10. Subpoena and Discovery Response Protocol

1. Any subpoena, records request or discovery demand that mentions recordings, transcripts, AI drafts, or "all recordings" is sent to the Oversight Officer the day it arrives and to defense counsel and the malpractice carrier before anything is produced.
2. The practice answers from what actually exists (section 4 and 5): no audio exists; the transcript exists only if the practice's setting keeps it and only within the retention window; the signed note is the record. The practice does not describe artifacts it does not hold.
3. Counsel is asked specifically about waiver-of-privilege risk connected to AI use before any AI-related material is discussed or produced.
4. PodScribe forwards any request it receives to the practice and produces nothing on its own initiative. Requests to PodScribe about this practice go to support@podiatry-scribe.com and are logged by the practice.

11. Annual Review and Adoption

This policy is reviewed at least annually against current state law, the vendor's terms and privacy policy, FDA and state regulatory developments, and the practice's own audit and incident findings. Workflows, audits and training are updated with it.