Issued2026-09

Position Statement 3.2.1 – Medical Records: AI-Assisted Documentation and Clinical Decision Accountability

Position StatementSector

Summary

Amends the Board’s medical-records position statement to address AI-assisted transcription and clinical recommendations. Places responsibility for transcription accuracy on the licensee and expects a defensible rationale for following AI recommendations and documentation of reasons for deviating from them.

Healthcare Implications

North Carolina licensees using AI scribes or decision support should verify documentation and retain clinical reasoning for AI-informed treatment choices. This is a Board position statement interpreting professional expectations, rather than a standalone AI statute or a requirement to follow AI advice.

Impact Level

Medium

Keywords

Clinical Quality & Efficacy; Safety & Risk; Transparency & Governance

Stakeholders

Providers & Health Systems; Patients & Public; Regulators & Government