Purpose

These guidelines establish a framework for the responsible use of artificial intelligence tools within the practice. They address AI use across clinical documentation, therapy planning, business operations, marketing, and billing to ensure compliance with applicable privacy laws, payer requirements, and professional ethical standards while enabling the practice to benefit from AI-assisted efficiencies.

Scope

These guidelines apply to all practice owners, employed and contracted speech-language pathologists, speech-language pathology assistants, clinical fellows, and administrative staff who use AI tools in any capacity connected to practice operations, including clinical services, scheduling, billing, marketing, and client communication.

Definitions

• AI Tool: Any software application that uses artificial intelligence, machine learning, or large language models to generate, summarize, or analyze text, data, images, or other content.
• Protected Health Information (PHI): Any individually identifiable health information related to a client’s past, present, or future health condition, treatment, or payment, as defined under HIPAA (45 CFR 160.103).
• AI-Assisted Content: Any clinical documentation, client communication, marketing material, or business document for which AI tools were used in drafting, editing, formatting, or generating any portion of the content.
• Clinician-Authored Content: Documentation written, dictated, or substantively composed by the clinician based on direct clinical observation and professional judgment, without AI drafting assistance.
• Informed Consent for AI Use: A written acknowledgment by the client or their authorized representative that AI tools may be used in specified aspects of their care or documentation.

Policy Statements

1. AI tools may be used to support clinical productivity and business operations, but they shall not replace the clinician’s professional judgment, direct clinical observation, or individualized treatment planning.
2. Clients or their authorized representatives must provide informed consent before AI tools are used in the preparation of clinical documentation related to their care.
3. All clinical documentation must clearly delineate between AI-assisted drafts and clinician-authored content through internal practice notation standards.
4. AI tools used with any client information must comply with HIPAA requirements. Tools processing PHI must be covered by a Business Associate Agreement.
5. Insurance and third-party payer documentation must accurately reflect services rendered by the clinician and must not misrepresent AI-generated content as the product of direct clinical activity.

Approved Uses

• Drafting clinical note templates, evaluation frameworks, and progress report structures using de-identified information.
• Generating therapy activity ideas, home program suggestions, and parent education handouts that do not contain client-specific information.
• Creating marketing content including website copy, blog posts, social media posts, and newsletter text, provided all clinical claims are evidence-based and reviewed for accuracy.
• Drafting administrative communications such as cancellation policies, intake instructions, and general practice announcements.
• Assisting with billing code research and documentation language to support medical necessity, reviewed by the responsible clinician before submission.

Prohibited Uses

• Entering client names, dates of birth, insurance information, or any PHI into AI tools that lack a Business Associate Agreement with the practice.
• Submitting AI-generated clinical documentation to insurance payers without substantive clinician review and individualization to the specific client encounter.
• Using AI to fabricate clinical observations, therapy data, or progress metrics not derived from actual sessions.
• Generating marketing content that includes client testimonials, case examples, or identifying details without explicit written consent.
• Using AI to make diagnostic or eligibility determinations without independent clinical assessment.

Data Protection Requirements

1. Any AI tool that processes client data must comply with HIPAA Privacy and Security Rules, and the practice must have an executed BAA on file with the vendor.
2. Client information entered into AI tools must be limited to the minimum necessary for the intended purpose.
3. Staff shall not use personal AI accounts or free consumer-grade AI tools for any work involving client information.
4. The practice shall maintain a current inventory of all AI tools in use and their data handling classifications (PHI-approved vs. de-identified use only).
5. In the event of a suspected breach involving AI tools, the practice owner must initiate the practice’s Breach Notification procedures immediately.

Disclosure Requirements

1. The practice’s intake paperwork shall include an AI Use Disclosure statement informing clients that AI tools may be used to assist with documentation, therapy material creation, or administrative tasks.
2. Clients must sign an informed consent form acknowledging AI-assisted documentation practices before such tools are used in connection with their care.
3. Upon request, clients shall be informed of which aspects of their documentation involved AI assistance and how the clinician reviewed and finalized the content.

Documentation Standards

1. Clinical notes prepared with AI assistance shall include the notation: “AI-assisted draft; reviewed, individualized, and finalized by [Clinician Name], [Credentials].”
2. The practice shall maintain a clear distinction in its internal records between AI-assisted and clinician-authored documentation.
3. Documentation submitted to insurance companies or third-party payers must accurately represent the clinician’s direct involvement in assessment, treatment, and documentation.
4. The treating clinician is the sole author of record for all clinical documentation and bears full professional responsibility for its accuracy and completeness.

Compliance & Accountability

1. The practice owner is responsible for maintaining the approved AI tools list, ensuring BAAs are in place, and enforcing these guidelines.
2. Violations of these guidelines may result in corrective action, additional training requirements, or termination of employment or contract.
3. All clinical and administrative staff shall review these guidelines upon hire and annually thereafter, with documented acknowledgment.
4. The practice owner shall monitor AI use practices through periodic documentation audits, conducted at minimum semi-annually.

Review Schedule

These guidelines shall be reviewed annually by the practice owner in consultation with clinical staff. Revisions shall be made as needed in response to changes in HIPAA regulations, payer requirements, state licensing board guidance, or ASHA practice standards related to AI use.

Acknowledgment

I, ______________________________ (printed name), acknowledge that I have read, understand, and agree to comply with these guidelines governing AI use within the practice.

Signature: ______________________________ Date: ______________

Role: ______________________________ License/Credential Number (if applicable): ______________________________

Practice Owner Signature: ______________________________ Date: ______________