AI in Mental Health Documentation: FAQ

An AI scribe is a software tool that uses artificial intelligence to assist with clinical documentation. It listens to or processes therapy session recordings and generates draft clinical notes in standard formats like SOAP, DAP, or BIRP. The clinician then reviews and finalizes the notes before they become part of the patient's record.

With MH Scribe, you record your therapy session (with patient consent). The audio is securely uploaded, transcribed using speech-to-text technology, and then an AI model analyzes the transcript to generate a structured clinical note. The entire process is encrypted and HIPAA-compliant. You review the draft, make any edits, and approve the final note.

No. AI documentation tools are administrative assistants, not clinical replacements. They handle the time-consuming task of note-writing so clinicians can focus on what matters most: the therapeutic relationship. AI does not provide therapy, make diagnoses, or influence treatment decisions. The clinician remains fully in control of all clinical judgment.

No. MH Scribe never uses your patient data, session recordings, transcripts, or notes to train, fine-tune, or improve AI models. This commitment is contractually guaranteed in our Business Associate Agreement and Terms of Service. Your clinical data is used solely to generate your documentation and is never shared with third parties for any purpose.

All data is encrypted using TLS 1.3 during transmission and AES-256 encryption at rest. Our infrastructure runs on AWS SOC 2 Type II certified servers located exclusively in the United States. Access is restricted through role-based controls and multi-factor authentication. Audio recordings can be automatically deleted after transcription is complete.

MH Scribe is fully HIPAA compliant. We sign Business Associate Agreements (BAAs) with all customers, implement comprehensive technical and administrative safeguards, maintain audit logging with six-year retention, and follow documented breach notification procedures. Our security practices are detailed on our Security page.

Only you, the clinician, have access to your patients' recordings and notes. MH Scribe implements strict organization-level data isolation, meaning no other user or organization can access your data. Our engineering team does not have routine access to customer PHI, and any access for support purposes requires explicit authorization and is fully audited.

Modern speech-to-text models achieve high accuracy rates for clear audio in standard clinical settings. Accuracy can vary based on audio quality, background noise, accents, and technical terminology. MH Scribe uses state-of-the-art transcription models optimized for clinical conversations. You always have the opportunity to review and correct the transcript before generating notes.

No. The AI generates documentation based on what was discussed in the session. It does not diagnose, recommend treatments, assess risk, or make any clinical judgments. All clinical decision-making remains entirely with the licensed clinician. The AI is a documentation tool, not a clinical advisor.

AI-generated notes are always drafts that require clinician review. You have full editing capability to correct, add, or remove any content before finalizing the note. This review step is a critical part of the workflow and ensures that the final clinical record accurately reflects your professional assessment of the session.

Yes. MH Scribe works with both in-person and telehealth sessions. For telehealth, you can record the session audio directly through your device. The documentation process is identical regardless of the session modality. MH Scribe also helps with appropriate telehealth modifier suggestions for billing.

Yes. Informed consent is both an ethical best practice and typically required by licensing boards and HIPAA regulations. Patients should understand that AI is being used in the documentation process, how their data is handled, and that they can opt out. MH Scribe provides a customizable consent form template to make this process straightforward.

We recommend a transparent, straightforward conversation. Explain that you are using a tool to help with note-taking so you can be more present during sessions. Emphasize that the system is HIPAA-compliant, their data is encrypted, and you review every note personally. For detailed scripts and tips, see our guide on introducing AI documentation to patients.

MH Scribe supports all major clinical note formats including SOAP, DAP, BIRP, and comprehensive intake/biopsychosocial assessments. You can select your preferred format and customize templates to match your practice's specific requirements. The AI generates notes in your chosen format consistently across all sessions.