Consumer-to-Clinical Language Shifts in Ambient AI Draft Notes and Clinician-Finalized Documentation: A Multi-level Analysis
Authors: Ha Na Cho, Yawen Guo, Sairam Sutari, Emilie Chow, Steven Tam, Danielle Perret, Deepti Pandita, Kai Zheng
Organizations: Department of Informatics, University of California, Irvine, Irvine, CA, USA · Institute for Clinical and Translational Science, University of California, Irvine, Irvine, CA, USA · Department of Medicine, University of California, Irvine, Irvine, CA, USA · Department of Physical Medicine & Rehabilitation, University of California, Irvine, Irvine, CA, USA
Ambient AI generates draft clinical notes from patient-clinician conversations, often using lay or consumer-oriented phrasing to support patient understanding instead of standardized clinical terminology. How clinicians revise these drafts for professional documentation conventions remains unclear. We quantified clinician editing for consumer-to- clinical normalization using a dictionary-confirmed transformation framework. We analyzed 71,173 AI-draft and finalized-note section pairs from 34,726 encounters. Confirmed transformations were defined as replacing a consumer expression with its dictionary-mapped clinical equivalent in the same section. Editing significantly reduced terminology density across all sections (p < 0.001). The Assessment and Plan accounted for the largest transformation volume (59.3%). Our analysis identified 7,576 transformation events across 4,114 note sections (5.8%), representing 1.2% consumer-term deletions. Transformation intensity varied across individual clinicians (p < 0.001). Overall, clinician post-editing demonstrates consistent shifts from conversational phrasing toward standardized, section- appropriate clinical terminology, supporting section-aware ambient AI design.
Department of Informatics, University of California, Irvine, Irvine, CA, USA · Institute for Clinical and Translational Science, University of California, Irvine, Irvine, CA, USA · Department of Radiological Sciences, University of California, Irvine, Irvine, CA, USA +3
Department of Informatics, University of California, Irvine, Irvine, CA, USA · Institute for Clinical and Translational Science, University of California, Irvine, Irvine, CA, USA · Department of Medicine, University of California, Irvine, Irvine, CA, USA +1
Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA · Stern School of Business, New York University, New York, NY · Department of Occupational Therapy, University of Pittsburgh, Pittsburgh, PA +3