Episode 178: If You Didn’t Say It, It Didn’t Happen: The Hidden Risk of Ambient Scribes
Ambient scribes are one of the most exciting developments we’ve seen in clinical workflows in years. They promise less typing, less burnout, and more meaningful connection with patients. And for many physicians, that alone feels like a long-overdue shift in the right direction.
But here’s the question: are they actually capturing the full clinical and financial story of the visit?
Because what I’m seeing, across practices of all sizes, is that while ambient scribes are incredibly helpful… they’re not the whole answer.
And this isn’t a knock on the technology. In fact, I think it’s one of the most important tools we’ve added to the clinical environment in a long time. But like any tool, its value depends entirely on how it’s used—and what we assume it’s doing for us.
So let’s start with what ambient scribes do really well, because there’s a lot to appreciate here. They reduce the physical and cognitive burden of documentation. Instead of turning your back to the patient and typing into a screen, you can stay engaged, make eye contact, and actually listen. That alone changes the dynamic of the visit in a meaningful way.
They also improve efficiency. Notes are often generated quickly, sometimes even in real time, which reduces the amount of after-hours pajama time charting that so many physicians have come to accept as normal. For some practices, that’s been transformative.
And they can help with recall. The system is capturing the conversation, which means fewer missed details, fewer forgotten elements, and a more complete record of what was said in the room.
So yes—this is a powerful tool.
But it’s still just a tool.
And where things start to break down is in the gap between what is said… and what is thought. Because if you think about how you practice medicine, so much of your value is not in what you say out loud. It’s in what’s happening internally.
During a typical patient visit, you’re constantly processing information. You’re building a differential diagnosis. You’re weighing risk. You’re deciding what matters and what doesn’t. You’re considering what could go wrong, even if it’s unlikely. You’re making judgment calls based on years—sometimes decades—of training and experience.
You might be thinking, “This is probably benign… but I can’t ignore the possibility that it’s something more serious.” Or, “I’m going to treat this conservatively, but I need to keep a close eye on it.” Or, “Given this patient’s history, this is actually higher risk than it appears.”
Those are sophisticated clinical decisions.
But here’s the problem: ambient scribes are only capturing what is spoken. And what is spoken is often a simplified, patient-friendly version of what you’re actually thinking.
So what ends up in the note looks much less complex than the actual visit.
And that has real consequences.
Because from a coding perspective, from a compliance perspective, and from a financial perspective, complexity matters.
Medical decision making—MDM—is one of the core drivers of E&M coding. And MDM is based on things like the number and complexity of problems addressed, the amount and complexity of data reviewed, and the level of risk.
If those elements aren’t documented, they don’t count.
So if you’re thinking through a complex differential diagnosis but only verbalizing a simplified conclusion, the note may reflect a lower level of complexity than what actually occurred.
And over time, that leads to undercoding. Not once in a while. Consistently.
And consistent undercoding is not a small issue. It’s a slow, steady erosion of your revenue. It’s an underepresentation of the work you’re doing. And in some cases, it can even create compliance concerns in the opposite direction—because your documentation doesn’t match the true acuity of your patient population.
Let me give you a simple example.
A patient comes in with chest pain. In your mind, you’re thinking through a range of possibilities. Musculoskeletal pain, sure. But also cardiac causes, pulmonary embolism, maybe even something gastrointestinal. You’re weighing risk factors, history, presentation.
But what you say out loud might be something like, “This is likely musculoskeletal. Let’s treat it conservatively and monitor.”
That’s appropriate communication for the patient.
But if that’s all that gets captured in the note, it tells a very different story than what actually happened cognitively.
And that difference matters.
So now we’re in a new reality where documentation is no longer just about what you type. It’s about what you say.
And that creates a new challenge.
Because you may now need to say things out loud that you used to simply think.
You may need to verbalize your differential diagnosis. You may need to articulate your risk assessment. You may need to explicitly state what you’re ruling in or ruling out, what data you reviewed, and why you made the decisions you made.
That’s a shift.
And it’s not always comfortable.
Because not everything you think is something you want to say in front of a patient.
There are moments in clinical care where your internal thought process includes possibilities that are serious, sensitive, or even alarming. You might be considering a diagnosis that would worry the patient unnecessarily if presented without context. You might be thinking about concerns related to compliance, behavior, or psychosocial factors that require nuance and care.
And now, with an ambient scribe listening, the question becomes: how do you document those thoughts appropriately without creating unintended consequences in the room?
This is where things get more complex.
Because on one hand, you need accurate documentation. You need to capture the full scope of your clinical reasoning. You need to support appropriate coding and protect yourself from a legal standpoint.
On the other hand, you need to maintain trust with your patient. You need to communicate in a way that is clear, compassionate, and appropriate for the situation.
So there’s a tension here.
And the solution is not to abandon the tool. It’s to evolve how we use it.
One of the most important skills that physicians will need to develop in this environment is intentional phrasing. Learning how to say what needs to be documented in a way that is both accurate and appropriate.
For example, instead of saying nothing about your differential diagnosis, you might say, “There are a few possibilities we’re considering here, including X, Y, and Z. Based on what I’m seeing today, I think this is most likely X, but we’re going to keep an eye on it.”
That communicates your thinking. It documents your complexity. And it does so in a way that is transparent but not alarming.
There will also be times when what you need to document is not something you want to say out loud in that moment.
And that’s where it’s important to remember that the ambient scribe should not be the final version of your note.
It should be the first draft.
You still have the ability—and the responsibility—to review, edit, and add to that note before it becomes part of the permanent record.
That might mean adding an addendum. It might mean refining language. It might mean documenting elements of your thinking that weren’t verbalized during the visit.
Because again, the goal is not just faster notes. It’s better notes. More accurate notes. Notes that reflect the true complexity of the care you’re providing.
Now let’s zoom out a bit and talk about the operational and workflow implications of ambient scribes, because there’s a lot happening here as well.
On the positive side, we’re seeing improved efficiency in many practices. Physicians are spending less time charting after hours. Notes are being completed more quickly. There’s a sense of relief that comes from not having to carry that documentation burden into the evening.
We’re also seeing improvements in patient engagement. When the physician is not focused on a screen, the interaction changes. Patients feel more heard. The visit feels more human. Patients even feel like you spent more time with them, even if you didn’t. They just feel better about the visit and the attention they got from you.
And from a staffing perspective, there may be opportunities to reduce reliance on traditional scribes or reallocate resources in a more efficient way.
Those are real benefits. But there are also challenges that need to be acknowledged. One of the biggest is over-reliance.
There’s a tendency to assume that the technology is handling the documentation completely. That what’s being generated is accurate, complete, and sufficient. And that’s not always the case.
Without a structured review process, errors can slip through. Omissions can go unnoticed. And over time, note quality can become inconsistent. There’s also a learning curve.
Physicians are being asked to shift from thinking internally to speaking externally. That’s not a small change. It requires awareness, practice, and in some cases, coaching.
Workflows may need to be adjusted. Time may need to be built in for review and refinement. Expectations need to be set clearly within the organization about what “done” looks like when it comes to documentation.
Another challenge is variability.
Different physicians will adapt to this technology differently. Some will naturally verbalize their thinking. Others will continue to process internally, leading to differences in documentation quality and coding outcomes across the group.
And that variability can create both financial and operational issues.
So what does a best practice model look like?
It’s not about choosing between ambient scribes and traditional documentation methods.
It’s about integrating the technology into a thoughtful system.
That system includes physician and clinician awareness. Understanding that what you think needs to be reflected in what is documented—and that may require more intentional verbalization.
It includes a structured review process. Notes should not be signed without being reviewed. There should be an expectation that the ambient output is a draft, not a final product.
It includes alignment with coding education. Physicians need to understand how their documentation supports—or fails to support—appropriate coding levels in this new environment.
And it includes periodic audits.
Looking at note quality. Looking at coding patterns. Identifying trends. Making adjustments.
Because what you don’t want is a slow drift toward underdocumentation and undercoding that goes unnoticed for months or years.
And this is where the broader message comes in.
Technology is moving quickly. Faster than most of us expected. And it’s solving real problems.
But it’s not replacing clinical judgment. It’s not replacing the need to communicate that judgment clearly. And it’s not eliminating the need for systems, processes, and oversight.
Ambient scribes are solving the problem of documentation burden.
They are not fully solving the problems of documentation accuracy, coding optimization, or clinical storytelling.
And those are still your responsibility.
So if you’re using an ambient scribe—or considering one—the question isn’t just, “Is this making my life easier?” It’s also, “Is this accurately reflecting the care I’m providing?”
“Is this supporting appropriate coding?”
“Is this improving—or potentially compromising—my documentation quality?”
Because at the end of the day, the goal is not just to get the note done. The goal is to tell the story of the visit in a way that is clear, complete, and accurate. To reflect the complexity of your thinking. To support the financial health of your practice. And to protect both you and your patient.
This is a powerful tool.
But like any powerful tool, it needs to be used with intention. It needs to be supported by good systems. And it needs to be understood—not just adopted.
If you’re already using ambient scribes, it may be worth taking a closer look at your notes. At your coding patterns. At how your workflows have changed.
And if you’re thinking about implementing this technology, this is the moment to design it well from the beginning.
Because when you get this right, you don’t just reduce documentation burden. You create better notes. Stronger systems. And ultimately, healthier, more sustainable practices.
Until next time…