Clinical documentation in gynecology: a reviewable workflow with AI

A linear note can bring together facts that do not have the same status. “Reports pelvic pain since May” is an account; a finding documented during an examination is a professional observation; a report provides documentary information. If the source disappears, an assumption may be interpreted as confirmation.

The Federal Council of Medicine defines the medical record as a single document composed of information of a legal, confidential, and scientific nature that also enables team communication and continuity of care (CFM Resolution No. 1,638/2002). Before becoming the final record, the draft must preserve authorship, source, and sequence.

Before clinical use, technical leadership should confirm with qualified professionals which rules and guidance are in force for the workflow, specialty, and context. Until that validation is complete, use clear patient information, complete physician review, auditing, monitoring, and the ability to stop use as minimum safeguards.

When a tool offers capture or transcription, AI can organize the content into an editable draft. It must not create a diagnosis, prescription, result, denial, or date that was not explicitly stated, or decide on its own what is clinically relevant.

In this editorial workflow, use distinct categories: not asked, when the topic was not explored; not provided, when an adequate response was not provided, including by choice; denied, only when there is an explicit denial; unknown, when the person says they do not know; and not applicable, after professional confirmation that the item does not apply to the context. Silence in the transcript must not automatically be converted into a denial.

The Medical Code of Ethics provides that the medical record must be legible and contain the necessary clinical data, entered in chronological order, with the date, time, signature, and CRM registration number. The AI output remains a draft until the professional reviews and approves it.

The framework proposed here brings together six adaptable blocks; it is not a mandatory form or a universal protocol. The Primary Care Protocols: Women's Health serve as a clinical reference without replacing local protocols or adaptation to the case.

1. Reason and priority. Document the reason for seeking care in the words of the person receiving care and the agreed-upon focus for the encounter. Separate symptoms, questions, follow-up, and administrative requests.

2. Symptoms and timing. Separate onset, duration, frequency, recurrence, changes, relationship to the cycle, and associated factors. Mark the date as exact, approximate, or unknown; do not turn vague expressions into precise dates.

3. Menstrual, reproductive, and obstetric history. Document the date of the last menstrual period, menstrual pattern, contraception, reproductive intentions, and obstetric events only when provided and relevant. Do not infer pregnancy from a late menstrual period or reproductive intentions from the contraceptive method.

4. Sexual health and sensitive context. Use neutral, nonjudgmental language. The CDC guide proposes a person-centered and trauma-sensitive sexual history; here, it serves as an international reference, not a Brazilian standard. Document only what was explicitly stated and is relevant to the encounter. If a support person is present, consider whether private time is needed and identify the source of third-party statements when they are clinically necessary. A transcription tool can organize the spoken content, but it does not decide whether the information should become part of the medical record; the professional makes that choice during review. If the person prefers not to answer, document the situation respectfully and do not turn the lack of a response into a denial or a presumed clinical fact.

5. History, medications, and allergies. Organize prior conditions, surgeries, family history, medications, and allergies. Confirm the substance, dose, route, and frequency; if an element was not stated, keep it marked as not provided.

6. Examination, documents, and plan. Separate reported symptoms from observed findings. Identify the source of external reports and the status of diagnostic tests. The assessment and plan must reflect only what the professional established.

For each event, preserve what happened, when it happened, the precision of the date, and the source. This helps avoid mixing up the onset of a symptom, a previous visit, the collection of a specimen, and the arrival of a result.

For tests, use independent statuses: ordered, performed or collected, result received, and result reviewed with the plan documented. Record the available date at each stage. A result received must not automatically be marked as reviewed; if a test was performed but no report is accessible, its result remains unavailable for verification.

Entirely fictional example, with no real person's data and created solely to demonstrate the format: “Bleeding outside the usual menstrual period; reported onset is approximate. Date of the last menstrual period reported as exact. External ultrasound reported as performed; report not presented; review pending. Complete blood count ordered during the encounter; collection has not yet been performed.” The draft does not add a result, diagnosis, or missing date.

Before: choose the clinical template, define the required fields, and prepare the in-person or remote setting. If capture or transcription will be used, explain the purpose and workflow in accordance with the clinic's governance and the principles of purpose and transparency under the LGPD. Consider the presence of a support person and the need for private time.

During: make complete dates, the source of documents, explicit denials, and changes in test status clear. When there is a relevant ambiguity, clarify it during the encounter. In telemedicine, CFM Resolution No. 2,314/2022 does not, on its own, establish a general requirement to fully record audio, images, and video. This does not amount to a general finding of compliance or an exemption applicable in every case: other laws and rules, institutional policies, contracts, and risks specific to the situation may impose duties or require a different assessment. The decision to record, transcribe, or not record must go through responsible governance and an analysis of the specific context.

After: compare the draft with what was discussed, review the timeline, and identify pending tests or follow-up visits. Correct terms, eliminate inferences, and approve, save, export, or share the final version only after professional review.

Use the checklist while reviewing the draft and before final approval. It serves as a review checkpoint, not as a substitute for clinical judgment.

Identification and language: verify the identity of the person receiving care, the encounter modality, date, time, signature, and professional registration number. Review abbreviations, pronouns, ambiguous terms, and sentences without a subject. These elements are part of the ethical requirements for the record (Medical Code of Ethics).

History and timing: confirm denials, the precision of menstrual and reproductive dates, the sequence of symptoms, and the source of each piece of information. Distinguish not asked, not provided, unknown, and not applicable.

Medications and tests: verify the substance, dose, route, frequency, allergy, and described reaction. For each test, check the order, performance or collection, receipt of the result, review, and pending items.

Then apply the matrix. Accept: keep a fact that is explicit, traceable, and consistent with the encounter. Edit: correct ambiguity, chronology, terminology, medication, or dose using confirmed information, without filling in details based on plausibility. Delete: remove inferences about diagnosis, pregnancy, violence, sexual orientation, gender identity, fertility, or reproductive intentions, as well as duplicates and details with no clinical purpose. Ask again: clarify a gap when it could change understanding or continuity of care. If the person does not wish to answer, document the appropriate status without pressuring them.

The LGPD classifies health data and data concerning a person's sex life as sensitive and establishes principles such as purpose, adequacy, necessity, and security. In the documentation workflow, this supports recording only what is necessary, limiting access, and avoiding the inclusion of every intimate statement in the medical record.

Recordings, transcriptions, copies, and exports need a purpose and rules for access, retention, and disposition that are compatible with the clinic's context. The applicable legal basis depends on the situation and must be defined through responsible governance; using a tool, on its own, does not ensure compliance with the LGPD.

For computerized medical records, integrity, authenticity, and confidentiality are requirements under Law No. 13,787/2018. The ANPD guide for small-scale processing agents provides guidance on practices such as access management, training, backups, and incident response, without amounting to certification or a guarantee of security.

When support persons are present, distinguish the account of the person receiving care from information provided by third parties and document only what is necessary. When violence is reported, separate the firsthand account, observed findings, and the team's response, without adding inferences; PAHO provides a regional reference specifically for this documentation. This separation organizes the record, but it does not replace risk and safety assessment, protective measures, care and referrals, notification when applicable, or the local protocol. Especially in situations of vulnerability, the responsible team must assess these steps based on the case, the applicable rules, and the institutional workflow; the PAHO clinical reference addresses the broader care response.

A voice-based medical record for gynecologists should move forward only when it turns the conversation into a clear review queue, not an automatic truth. AI can support the initial organization, but final approval remains with the professional.