Clinical AI Use Policy

Purpose

This policy defines the approved use of AI/Abridge by residents in the University of Chicago Medicine (UCM) Internal Medicine Residency Program to support clinical documentation during patient encounters while ensuring patient consent, data integrity, and appropriate supervision.

Scope

This policy applies to eligible Internal Medicine residents using AI/Abridge during direct patient encounters in approved clinical settings.

Approved Clinical Settings

Abridge may be used only for direct patient encounters in the following settings:

• Continuity clinic
• Urgent/Immediate care clinic
• Inpatient rotations
• ED

Use of Abridge outside of direct patient encounters (e.g., teaching rounds, handoffs, case conferences, evaluations, or informal discussions) is not permitted.

Resident Eligibility

Only PGY-2 and PGY-3 residents will be eligible to register for and use Abridge.

• Prior to first use, eligible residents must complete a program-designated ambient AI orientation covering consent workflows, documentation review expectations, and common AI error patterns.
• Completion will be tracked by the program coordinator.
• Eligibility will be reviewed yearly.

PGY-1 residents (interns) are not permitted to use Abridge.

Supervision and Attending Responsibility

Attending physicians retain standard supervisory responsibility for all documentation.

AI-assisted notes are subject to the same expectations for review, attestation, and accuracy as traditional documentation.

Patient Consent Requirements

Residents must obtain verbal consent from the patient prior to using Abridge at each encounter. For visits involving family members or other third parties in the room, verbal consent must be obtained from all participants.

Consent must be documented in the medical record using the standard ‘.ABRIDGEVERBALCONSENT’ smartphrase.

If a patient declines consent, Abridge must not be used, and the declination must be documented in the medical record.

Patients may decline without impact on their care.

Documentation and Review Responsibilities

Abridge-generated content is intended to support documentation only.

Residents are fully responsible for reviewing Abridge output for accuracy, completeness, and appropriateness.

Residents must correct any errors, omissions, or inaccuracies prior to forwarding to attending faculty for attestation.

Use of Abridge does not replace clinical judgment or professional responsibility.

• Residents should meaningfully edit and synthesize AI-generated content.
• Residents should not rely on AI output without verification

Data Privacy and Governance

Use of Abridge must comply with all institutional privacy, security, and HIPAA policies.

• Recording without patient consent is strictly prohibited.
• Ambient AI may only be used on hospital-issued mobile devices or personal devices that meet the institution’s mobile device management (MDM) and encryption requirements.
• The resident must be physically present in the room during the entire recording duration to prevent “passive” recording of private family conversations.

AI-generated content and audio recordings must not be used for teaching, research, or external sharing unless explicitly approved through appropriate institutional processes.

Policy Review and Reassessment

Use of Abridge within the Internal Medicine Residency Program will be revisited and reassessed in annually in June.

Continued approval may be modified or revoked based on program evaluation, compliance, or institutional guidance.

Compliance

Failure to comply with this policy may result in revocation of Abridge access and may be addressed through residency program professionalism or disciplinary processes, as appropriate.

Other AI use

Residents should NEVER put Protected Health Information (PHI) into non UCM approved AI models (Chat GPT, Claude, Gemini, DoxGPT etc) · Approved AI systems can be found on the UCM Intranet these include but are not limited to Phoenix AI, UpToDate, etc

Residents are encouraged to use Open Evidence or other medical based search engines that link to primary articles or reviewed literature for searching medical content

Other Ambient Listening Scribe technology (i.e. Doximity Scribe) are not allowed