How Practitioners Are Using AI Scribes for Letters, Reports, and Referrals

The paperwork that never quite gets done

Caitlin Cormier, speech-language pathologist and owner of Halton Hills Speech and Language Services, put it plainly in a Jane webinar on AI Scribe in solo practice: "It's really hard to remember what my client at 8 am said when it's 6 PM." She'd allocated 15 minutes between clients for documentation. In practice, that time got eaten by other things, and by the end of the day, the clinical details had already started to fade.

For most practitioners, that same problem doesn't stop at session notes. It follows you into the referral letter you meant to write after your 10 am patient, the discharge summary sitting in a tab, and the insurance report that's technically past due. Session notes get all the attention when AI tools for therapists come up, but for a lot of practitioners, therapy notes aren't always where the time goes, it's that other pile of documentation too.

How to use an AI scribe for referral letters and reports

The same tool that turns a post-session recording into a SOAP or session note can also turn a spoken summary into a referral letter or discharge note. Think of it the way you'd think of medical transcription software, except instead of transcribing a live session, you're speaking a structured summary after the fact: who the patient is, what the situation is, and what you need the document to say, then the AI scribe shapes that into a structured, professionally worded document.

Caitlin's framing for prompts is a helpful one to think about here. She suggests thinking of it like debriefing a student, where you're telling the tool what you want the document to look like and what components need to be in it. It took her about two weeks to get her prompts exactly where she wanted them. In her words: “Take time up front investing in those prompts. It really pays off in the long run.”

For letters and reports, dictating after the session tends to work better than trying to capture and record the live conversation, and the output is a draft you review, adjust, and send. If you want to dig into when it’s best to dictate vs. record your client conversations, check out our article on AI Scribe: Ambient Listening vs. Dictation.

How other practitioners are using AI scribe tools to support their documentation

Physiotherapists and physical therapists

AI for physical therapy documentation can be used for more than session notes. Referral letters, discharge summaries, and progress reports can follow a super similar workflow. A physical therapist referring a patient to an orthopedic specialist or sports medicine physician can dictate a two to three-minute summary right after the session and have AI Scribe draft the letter for them to review and send. Some common documents this works well for:

• Referral letters for specialists, including the patient's background, mechanism of injury, treatment to date, response to care, and the specific ask
• Discharge summaries when a patient's treatment goals are met or they're moving to a home program
• Progress reports for insurers or third-party payers, particularly the narrative sections covering functional status, treatment provided, and prognosis.

Sean Overin, physiotherapist, Director of Learning at Tall Tree Health, and co-founder of AMP Healthcare Education, reflected on this in a recent webinar on how AI Scribe is changing clinic charting. He uses a template to generate patient-facing treatment plans built from four things: what the patient has, what the prognosis is, what their goals are, and what their specific instructions and follow-up schedule look like. That summary goes directly to the patient after the appointment. Sean noted that, depending on the person, he finds 50 to 70% of what's said in a session is often forgotten by patients, and the treatment plan they receive is a direct response to that.

Counsellors and psychotherapists

For counsellors and psychotherapists, the documents that take the most time tend to follow consistent formats, require a professional tone, and contain clinical content that's specific to the client. That combination makes this workflow a natural fit for several documents counsellors produce regularly:

• Accommodation and support letters, where dictating a brief summary of the client's presentation, functional impact, and the specific request gives AI Scribe enough to produce a solid draft
• Letters to primary care providers flagging something that came up in session or coordinating care with a prescribing physician
• Therapy discharge and termination summaries covering the presenting concern, course of work, progress made, and any recommendations for ongoing support

Chiropractors

Many of the documents that take up time in a chiropractic practice follow consistent formats, which makes them well-suited to a dictation-based workflow:

• Referral letters for imaging (X-ray, MRI, CT), where you dictate the clinical picture and the specific imaging request
• Letters to primary care physicians and coordination letters for shared patients
• Motor vehicle accident (MVA) documentation, including letters to insurers, treatment reports, and functional status updates, where a consistent format and specific clinical language matter most

Massage therapists

For massage therapists, a significant portion of the documentation load sits outside the treatment room entirely, in the billing letters and referrals that extended health plans and shared patients require.

• Insurance billing letters and treatment reports for extended health plans, where a brief, dictated treatment summary gives AI Scribe enough to cover the required elements

• Referral letters to other practitioners

Acupuncturists and integrative health practitioners

Acupuncturists and integrative health practitioners often sit at a coordination point in a patient's care, communicating observations to GPs, naturopaths, and other specialists who may not share the same clinical language or framework. That's where a well-written letter adds value, and also where the writing barrier tends to slow things down.

• Letters to GPs and specialists summarizing treatment approach, observed patient response, and any clinical findings worth flagging to the broader care team

• Reports to naturopathic or integrative care teams coordinating shared patient care, where your observations from an acupuncture lens can add context other practitioners don't have

• Documentation for extended benefit claims, where a brief dictated treatment summary covering modality, frequency, and clinical rationale gives AI Scribe enough to produce a draft that covers the required elements

Before you use AI tools for regulated documents, check with your governing body

Before Caitlin started using AI Scribe for documentation beyond session notes, she contacted her governing body, CASLPO, to confirm the approach aligned with their professional and ethical standards. She also specifically looked into whether this method raised privacy concerns, where recordings were stored, and whether it was consistent with her obligations as a regulated professional.

If you're not sure, consult your governing body before you start. The right answer will depend on your profession, your province or state, and your specific regulatory body, especially if you're producing documents like referral letters, insurance reports, or formal clinical summaries.

If you want to read more on the HIPAA/PIPEDA compliance of AI scribes, you can learn more from our article Are AI Scribe Tools HIPAA and PIPEDA Compliant for Therapists?

A practical way to start, and what to keep in mind once you do

Pick one document type you write regularly and try dictating it instead of writing from scratch. Referral letters are often the easiest starting point because the format is consistent and you're reviewing it before it goes anywhere anyway. Right after a session, while the details are still clear, spend two or three minutes speaking through what you want the letter to say: who the patient is, what brought them in, what you've done, and what you're asking for.

Whatever the document, your review before it goes out is not an optional step. Clinical details, dates, the correct name of the receiving provider, and the specific ask in a referral: these all need your eyes for a quick double check. The quality of what you get back is proportional to the clarity of what you put in, so a vague two-sentence dictation usually produces a vague letter, while a clear spoken summary produces something much closer to ready.

Frequently asked questions

Can I use AI scribe tools without recording my sessions?

Yes, and for the document types covered in this article, dictation is actually the more common approach. Instead of recording a live session, you speak a summary after the fact: who the patient is, what happened, and what you're asking for. The AI scribe processes that dictation and drafts the document. For referral letters, discharge summaries, and insurance reports, a post-session spoken summary usually gives you more control over the output than a live recording would because you're narrating the clinical picture you want captured rather than everything that was said in the room.

Can an AI scribe pull in context from previous chart notes when writing a letter or report?

If you're using Jane's AI Scribe, yes. In the chart edit modal, you'll find a checkbox to reference your most recent 10 signed chart entries in the draft, as well as a checkbox to pull in the most recent intake form. For therapy discharge summaries and progress notes where treatment history matters, switching on those options will be really helpful. For referral letters where you're telling a specific clinical story to a specific recipient, dictating all of that context directly still gives you the most control over what ends up in the draft and how it's framed.

Does a tool like AI scribe work for my discipline? I work with non-verbal patients, pediatric clients, or couples.

Yes, because the dictation-based workflow doesn't depend on transcribing a conversation, it works well in settings where a live session recording wouldn't capture much useful clinical content anyway. If you work with non-verbal patients, young children, or in couples or family therapy where the dynamic is complex, you'd dictate your clinical observations and session summary after the fact to create something like a referral letter or report. What you say into the dictation is what drives the output, so the workflow adapts to your setting rather than requiring your setting to adapt to it.

Does AI scribe work on mobile or iPad?

Yes, you can dictate from your phone or tablet, which makes the right-after-the-session workflow a lot more practical. If you're moving between rooms, finishing up at a patient's bedside, or stepping out of a session and want to capture your thoughts before they fade, you don't need to be at a desk to do it. If you’re using Jane’s AI Scribe, check out the AI Scribe Help Hub for the latest info on supported devices and setup.