AI clinical notes vs. human notes: a comparison

If you're a mental health professional, you may be curious about AI for clinical notes and may be beginning to think about trying out an AI documentation tool. 

Some healthcare providers already embrace AI because they see it as a way to spend more crucial one-on-one time with patients instead of wrestling with paperwork. Others worry that technology could undermine the human aspect of therapy and mental health support.

Whichever side you lean, the research shows that most of us see its potential rather than pitfalls as long as AI is accompanied by human supervision. AI is here to stay and is already changing the care landscape. But how exactly do AI notes compare to handwritten notes? I decided to give Upheal a try and share my personal insights into how Upheal’s AI notes will compare to the process and resulting hand-written ones. 

How AI notes compare to handwritten ones 

Since I knew it would be for a few test sessions, I decided to use Upheal with an ex-colleague and look at the clinical data it captured as well as the various benefits and drawbacks. Using the product was extremely easy and intuitive. The below things stood out almost immediately. 

• Consistency: I found Upheal’s AI-generated notes to be very consistent and uniform across sessions. These notes can be even more consistent than human written notes, especially for those who tend to rush to try to catch up on note writing. Using AI notes can create consistency in a clinician’s process too, since they are reliably finished as soon as a session is over. This makes it very easy to review them right after the session on the same day.
  
  
• Time savings: Implementing AI notes can save five to ten hours per week for most clinicians. Upheal data shows this can be up to 40 hours per month. For me, the time savings came from the notes being automatically generated. I also found the Smart edit feature to be especially helpful on AI notes. Upheal’s Smart edit allows you to automatically shorten the note, as well as convert parts of the note to bullets. 
  
  
• Accuracy: Both AI and human written notes can be prone to problems with inaccuracies – a tired therapist may write typos, and AI can generate hallucinations. Hallucinations are most likely to occur in cases where the AI doesn't have sufficient information. They can also result from incorrect assumptions made from data or basic processing errors. Of course, manually generated clinical notes can also be prone to error or incompleteness too. According to one study one in five patients who have read a clinical note report finding a mistake. The golden rule is that it is essential to read through every note, AI generated or not.
  
  However, a benefit of using an AI tool is that the software can reduce errors in the more mundane parts of data capture such as session starts, endings, dates, names, scheduling, and so on, by automating these functions. When it comes to the clinical aspects of the notes, they must be reviewed every time anyway, since a clinician should retain expertise and always check for bias, integrity, and accuracy.
  
  

• Insights: Unlike notes that are recorded by hand and filed away, AI-generated notes can provide unique insights. I’m not sure that all AI tools provide this feature, but Upheal offers metrics for tracking client data points related to speech that can help show progress over time. This can help therapists make informed, whole-picture treatment and intervention decisions by looking at session analytics that uncover additional clinical insights like response time and sentiment, which can be used to track and improve client progress.
  
  
• Increased presence: Have you ever had the experience of mentally going through the tasks you need to "check off" for a session when you should be listening to a client or providing feedback? Therapists are only human. The mind can wander to the administrative side of therapy while a session is happening. Using Upheal allows you to be more present with your client. It can help take your mind off paperwork so you can focus on your client 100%.
  
  
• Versatility: AI-generated notes are much more versatile than human-written notes. For example, Upheal can create and swap between GIRP, BIRP, SOAP, DAP, and EMDR notes as well as two types of intake note (a comprehensive biopsychosocial intake note and a more standard intake assessment). All you have to do is click change note type and your note will be updated to the note template of your choice. When you write notes by hand, it’s not so simple.
  
  
• Cost: One of the advantages that human-written notes have over AI is that it costs nothing to write these notes. What many clinicians don’t know is that you can also use AI for free, too! Upheal has very recently released a free plan that includes unlimited notes and a range of features including notes from dictation, recordings, or typed text. Plus, the AI can be paused for sensitive topics.
  
  
• Eco worries: One thing that isn’t talked about much are the ecological implications of AI. It’s true that AI takes up a lot of energy. However, that’s something for us all to collectively be aware of and work on across industries.

What about legal considerations?

One of the legal considerations when it comes to writing therapy notes is privacy. Therapists are required to protect the privacy of their clients’ protected health information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA) in the United States, the Privacy Act in Australia and The Personal Information Protection and Electronic Documents Act (PIPEDA) in Canada. 

Upheal requires informed consent for the handling of client’s protected health information (PHI). This means that therapists must get permission from the client to allow the use of data processing by Upheal in regard to their personal information. 

However, some clients may hesitate to allow the processing of their data by AI. Studies have examined client’s views on the security of their data when it comes to AI applications. One study found that participants trusted human therapists more than AI-based applications when it came to the security of their data. 

Upheal is completely committed to ensuring that client data remains confidential and protected. With Upheal’s features, therapists can maintain confidentiality. To maintain client anonymity, therapists can create anonymous clients. They can also pause the AI for sensitive topics. Additionally, audio recordings are automatically deleted. 

AI vs. human notes: what the research says  

There's some good scientific data on AI-generated clinical notes vs. human notes. For example, research out of Stanford shows that AI can outperform humans in writing medical summaries. As part of a study, Stanford University researchers adapted eight large language models (LLMs) to clinical text to test their summarization skills against the work of human medical experts. In most cases, physicians had a preference for the notes prepared by AI over notes prepared by humans. In fact, several studies show AI-generated notes may be equal to or better than human-generated notes.

Does this mean that care providers should make the leap to AI in clinical documentation without ever looking back? Not quite yet. When researchers at Stanford were asked about the value of AI in psychotherapy, their response was that AI should be seen as a type of "supercharged secretary" for clinicians. When used correctly, AI can be valuable for intake interviews, documentation, notes, and other basic tasks. While AI comes with many different feelings and assumptions, the reality is that it should be viewed the same way as any other task-management technology therapists and millions of other healthcare professionals use daily.

Is it time to embrace AI clinical notes as a therapist?

Many therapists are experiencing burnout. The American Psychology Association (APA) shares that 38% of U.S. licensed psychologists are working more than they did before the pandemic. As a result, nearly half (45%) of therapists report feeling burnout. Burnout can hinder your effectiveness as a therapist and can also make you more likely to leave your chosen profession. 

Furthermore, for many therapists, the fear of taking on more administrative work can actually prevent therapists from expanding their practices even though they have the capacity to see more clients. 

In addition to stifling your potential for professional growth, fear of overload also contributes to the shortage of qualified professionals in the mental health field today. For these reasons, it’s essential to find a note-taking process that is efficient and effective, plus, AI can help if you’re feeling the weight of the following:

1. You don’t have enough hours in the day 

Simply put, the first reason to try AI notes is that you just don’t have enough time to take care of yourself, your clients, or your practice. The average therapist devotes hours to note-related tasks each week. 

These are hours that could have been spent with clients or unplugging and taking care of your own personal well-being. Recording notes is one of the most arduous administrative tasks a therapist deals with on a daily basis and takes up valuable time which could be used for your professional or personal pursuits.

2. You want to reduce your cognitive load but improve your accuracy

Managing notes is truly a "brain" activity that pulls your energy and cognitive attention down a rabbit hole. Even therapists who are highly organized and structured in their management styles often struggle with the following:

• Constant errors and inconsistencies in notes caused by trying to rush the task.
• Difficulty finding an organizational system that makes filing and referencing notes easy.
• Difficulty retrieving specific note files when information is needed.
• Fears of a client's privacy or confidentiality being breached when "paper" notes are stored in the office.

In short, with AI notes you’ll be guaranteed a higher level of consistency and organization, reducing the chance of human error. That’s not to say that the AI notes will be 100% perfect, in fact, you should always review any AI notes you’re signing off on. However, you’ll be able to rest easier knowing certain things like time stamps, quotes, and even scheduling, are taken care of automatically, reducing your cognitive load.

3. You’d like to deepen the therapeutic alliance with certain clients

The flip side of saving time and being able to delegate note-taking and data capture means that you can give your clients your full attention. That’s essential for high-risk cases, as well as initial sessions, and generally builds up an atmosphere of safety and trust. This may be important for certain clients who need that extra care.

4. You aren’t a natural writer, have ADHD, dyslexia, or other learning challenges

Not being a natural writer or having a neurodivergent brain doesn’t mean you aren’t a good therapist. Nor should you have to spend hours of additional time suffering through your documentation. We’re all different. The best thing about using AI notes is that they can support those of us who have writing or comprehension difficulties and/or struggle with attention-related aspects. And even if you’re a fast and organized writer, it’s still nice to be able to delegate aspects of the process so that you can be really, fully, present in the room.

Final thoughts on my experience with Upheal’s AI notes 

Ultimately, the debate doesn't have to come to AI-generated clinical notes vs. human notes. AI therapy notes can be supplements to human work instead of replacements. That said, clinicians should not lean on AI therapy notes 100% when managing client treatments. 

While AI can make documentation more efficient, it's important to remember that the therapist is still 100% responsible for the content of a finalized note. And does not, nor cannot, have the full responsibility of treatment for a human being. 

However, together with AI, therapists can create high-quality notes that are mostly complete and require only a human touch before final submission. Therefore, I can see a place for both: human proofreading and experience-based insights could be added to "mostly complete" notes that are generated by AI. Having most of the data capture work done by AI means that you will have more time and mental energy to interject your thoughtful insights or observations with a fresh eye.