Glossary.

Definitions for psychiatric documentation and AI-scribe terminology. Every term links back to the guides and reviews that use it.

AI Scribe: Software that produces a clinical note from a visit conversation.
Ambient Scribe: An AI scribe that captures the visit conversation in real time.
Asynchronous Scribe: A scribe that generates a note from a recording uploaded after the visit.
Dictation: Speech-to-text software that transcribes a clinician's monologue.
Speaker Diarization: Labeling which speaker said each part of a transcript.
Transcription Accuracy (WER): How faithfully the scribe converts speech to text.
Hallucination: A scribe producing content that was not said in the visit.
SOAP Note: Subjective, Objective, Assessment, Plan — the classic clinical note structure.
BIRP Note: Behavior, Intervention, Response, Plan — a therapy note format.
DAP Note: Data, Assessment, Plan — a compact therapy note format.
GIRP Note: Goal, Intervention, Response, Plan — a goal-anchored therapy format.
PIRP Note: Problem, Intervention, Response, Plan — a problem-anchored therapy format.
H&P Note: History and Physical — a comprehensive admission or intake note.
History of Present Illness (HPI): The narrative of the current episode of illness.
Mental Status Exam (MSE): Structured observation of a patient's current mental state.
Differential Diagnosis: The ranked list of candidate diagnoses under consideration.
Case Formulation: The clinician's synthesis of biological, psychological, and social factors.
Treatment Plan: The written plan of goals, interventions, and measures.
DSM-5-TR: The current diagnostic manual for psychiatric disorders.
ICD-10-CM: The diagnosis code set used for US billing.
CPT Codes: Procedure codes used to bill psychiatric services.
E&M Coding: Evaluation and Management code selection for medical visits.
Measurement-Based Care (MBC): Using validated symptom scales to guide treatment.
PHQ-9: Nine-item depression severity screener.
GAD-7: Seven-item generalized anxiety screener.
C-SSRS: Columbia Suicide Severity Rating Scale.
HIPAA: US health-information privacy and security law.
Business Associate Agreement (BAA): HIPAA contract between a covered entity and a vendor.
Protected Health Information (PHI): Individually identifiable health information under HIPAA.
42 CFR Part 2: Federal rule protecting substance use disorder records.
SOC 2: Auditor-attested controls report for security and availability.
HITRUST CSF: A prescriptive healthcare security certification framework.
Encryption at Rest: Encrypting stored data on disk or in a database.
Encryption in Transit: Encrypting data on the network.
Audio Retention: How long a scribe stores visit audio.
Subcontractors / Subprocessors: Downstream vendors that also handle PHI.
On-Premise vs Cloud: Where the model runs — customer infrastructure or vendor cloud.
Zero-Retention LLM Endpoint: An LLM API that discards inputs and outputs after inference.
Electronic Health Record (EHR): The system of record for patient charts.
EHR Integration: Direct programmatic connection between scribe and EHR.
FHIR: The modern healthcare data interoperability standard.
SMART on FHIR: A standard for launching third-party apps inside an EHR.
Note Turnaround Time: Time from visit end to a signable draft.
Note Template: A structured skeleton that shapes the generated note.
Custom Template: A clinician-built template.
Medication Management Visit: A psychiatric follow-up focused on pharmacotherapy.
Psychiatric Evaluation: The initial comprehensive psychiatric assessment.
Risk Assessment: Structured evaluation of suicide and violence risk.
Safety Plan: A written plan of coping steps and contacts for a patient at risk.
Telepsychiatry: Psychiatric care delivered over video or phone.
Collaborative Care (CoCM): A team-based model integrating psychiatry into primary care.
e-Prescribing: Electronic transmission of medication orders to a pharmacy.
Prior Authorization: Payer approval required before a medication or service is covered.
Collateral Information: Information about the patient from a third party.
Countertransference: The clinician's emotional response to a patient.