Informed Consent for AI-Assisted Care Documentation

CareTraceAI

What Is This Form About?

This form explains how your assisted living facility uses a technology tool called CareTraceAI to help document the care you receive. We want you (or your family member or legal representative) to understand what this tool does, how it works, and what it means for your personal health information.

Please read this form carefully. If you have questions, ask a staff member or contact us at privacy@caretrace.ai. You may also ask for this form to be read aloud to you.

Your participation is completely voluntary. You may choose not to have this tool used for your care documentation, and your choice will not affect the quality of care you receive in any way.

Section 1: What Is CareTraceAI?

CareTraceAI is a voice documentation tool used by nurses and caregivers at your facility. Here is how it works in simple terms:

1. Your caregiver speaks their notes aloud. After observing your condition, assisting you, or providing care, your nurse or caregiver speaks their observations into a secure application on their phone or tablet. For example, a caregiver might say: “Mrs. Johnson had a good appetite at lunch, ate about 75% of her meal, and was in good spirits during the afternoon activity.”
2. The app listens and creates a written version. Artificial intelligence (AI) technology converts the caregiver’s spoken words into written text — similar to how a voice-to-text feature works on a smartphone.
3. The app organizes the notes. A second AI system takes the written text and organizes it into a structured care note with clearly labeled sections (such as nutrition, mood, activities, vitals, and so on).
4. Your caregiver reviews everything. Before any note is saved to your record, your caregiver reads through it, makes any corrections needed, and approves it. No note goes into your file without a human caregiver reviewing and approving it first.
5. The approved note is saved. Once the caregiver confirms the note is accurate, it is saved as part of your care documentation.

What CareTraceAI Is NOT

• CareTraceAI is not a medical device.
• CareTraceAI does not diagnose conditions or recommend treatments.
• CareTraceAI does not make decisions about your care.
• CareTraceAI does not replace your caregiver’s professional judgment.

It is simply a tool that helps your caregivers write their notes more quickly and consistently, so they can spend more of their time caring for you.

Section 2: How Artificial Intelligence Is Used

CareTraceAI uses two types of artificial intelligence (AI) to assist with documentation:

Voice-to-Text (Transcription)

When your caregiver speaks their notes, AI technology listens to the audio and converts it into written words. This is similar to using the speech-to-text feature on a phone, but it is designed to work well with medical and care-related language.

Note Organization (Structuring)

After the spoken words are converted to text, a second AI system reads the text and organizes it into a structured clinical note. For example, it might place information about your meals under a “Nutrition” heading, and information about your mood under a “Behavioral/Mood” heading.

Important Limitations of AI

We want you to understand that AI technology is not perfect. Here are some of its known limitations:

• It may mishear words. The voice-to-text AI might occasionally get a word wrong, especially with names, medical terms, or accented speech.
• It may leave out details. The organizing AI might miss a detail that the caregiver mentioned, or place information under the wrong heading.
• It may misinterpret context.The AI does not truly “understand” what it hears the way a person does. It processes patterns in language, which means it can sometimes structure information incorrectly.

How These Limitations Are Addressed

Every AI-generated note is reviewed by your caregiver before it is saved. Your caregiver reads the note, checks it for accuracy, corrects any errors, and only then approves it for your record. The AI assists with writing — but a trained human being is always responsible for the final content.

The AI never makes care decisions. It does not recommend medications, suggest diagnoses, or influence your treatment plan in any way. All clinical decisions are made by your care team, as they always have been.

Section 3: What Information Is Collected

When CareTraceAI is used to document your care, the following types of information may be involved:

Voice Recordings

Your caregiver records their own spoken observations about your care. You are not being recorded. The caregiver is describing what they observed while caring for you. However, if you happen to be speaking nearby when a recording is made, your voice could incidentally be captured in the background.

Personal Identification Information

To create your care notes, the system uses identifying information such as:

• Your name
• Your room number
• Your date of birth
• Your medical record number (if applicable)

Health and Care Information

The content of the care notes may include:

• Observations about your physical condition (e.g., appetite, mobility, skin condition)
• Vital signs (e.g., blood pressure, temperature, pulse)
• Medications given and your response to them
• Your mood, behavior, and cognitive observations
• Activities you participated in
• Care actions taken by staff (e.g., assistance with bathing, repositioning)
• Any follow-up needs or concerns noted by your caregiver

Section 4: How Your Information Is Protected

We take the security of your personal and health information very seriously. Here is how we protect it:

Encryption

All information is encrypted (converted into a secure code) both while it is being sent over the internet and while it is stored on our servers. This means that even if someone were to intercept the data, they would not be able to read it.

Limited Access

Only authorized staff membersat your facility can view your care notes. Access is controlled by secure login credentials and role-based permissions. Not every employee can see every resident’s records — staff members can only access the records they need to do their jobs.

HIPAA Compliance

CareTraceAI is designed to comply with the Health Insurance Portability and Accountability Act (HIPAA), which is the federal law that protects your health information. We follow the standards required by HIPAA for handling, storing, and transmitting your Protected Health Information (PHI).

Audio Recording Deletion

The voice recordings made by your caregiver are automatically deleted after they have been processed into written text. The recordings are not kept long-term. Only the written, caregiver-approved notes are retained as part of your care documentation.

Audit Trail

Our system maintains a detailed audit trail, which is a log that records who accessed your information, when they accessed it, and what they did. This helps ensure accountability and allows the facility to monitor for any unauthorized access.

Data Storage

Your information is stored on secure servers within the United States. We use industry-standard security measures to protect against unauthorized access, data breaches, and data loss.

Section 5: Your Rights

You have important rights regarding your health information and the use of this technology. These rights include:

Right to Access Your Records

You have the right to view and obtain copies of the care documentation created about you, including notes generated with the assistance of CareTraceAI.

Right to Request Corrections

If you believe any information in your care documentation is inaccurate or incomplete, you have the right to request a correction. Your facility will review your request and make appropriate updates.

Right to Know Who Has Accessed Your Records

You have the right to request an accounting of disclosures— a list of who has accessed your health information, when, and for what purpose.

Right to Receive Copies of Your Records

You have the right to request and receive a copy of your care records in a readable format.

Right to Revoke This Consent

You have the right to withdraw your consent at any time. If you revoke consent:

• CareTraceAI will no longer be used to document your care going forward.
• Your facility will return to manual documentation methods (handwritten or traditionally typed notes) for your records.
• Any documentation that was already created and approved using Care Trace will remain part of your care record, as it was reviewed and approved by your caregiver at the time it was created.
• Your quality of care will not change. Opting out of AI-assisted documentation does not affect the care services you receive.

To revoke your consent, notify your facility administrator in writing, or contact us directly at privacy@caretrace.ai.

Section 6: Benefits and Risks

Potential Benefits

• More timely documentation. Caregivers can record observations shortly after providing care, while details are fresh, rather than waiting until the end of a shift to write everything down.
• More consistent notes. The structured format helps ensure that important categories of information (nutrition, mood, vitals, etc.) are consistently documented.
• More time with you. By reducing the time caregivers spend on paperwork, they can spend more of their shift providing hands-on care and attention to residents.
• Fewer missed details. Speaking notes aloud in the moment can help caregivers capture observations they might otherwise forget by the end of a busy shift.

Potential Risks

• Transcription errors. The AI may occasionally mishear or misinterpret words spoken by your caregiver. This risk is reduced because every note is reviewed and corrected by a caregiver before it is saved.
• Structuring errors. The AI may place information under the wrong category or miss a detail during organization. This risk is also reduced by caregiver review before the note is finalized.
• Data security. As with any electronic system, there is a possibility of a data breach or unauthorized access. This risk is reduced through encryption, access controls, audit logging, HIPAA-compliant practices, and prompt deletion of audio recordings.
• Incidental voice capture. If you are speaking near a caregiver while they are recording a note, your voice may be incidentally captured. Audio recordings are deleted after processing, and the written notes reflect only the caregiver’s clinical observations.

Section 7: Voluntary Participation

Your consent to the use of CareTraceAI for your care documentation is entirely voluntary.

• You are free to decline the use of this technology without any penalty or change in the care you receive.
• You are free to withdraw your consent at any time after signing this form, without any penalty or change in the care you receive.
• If you choose not to participate, your caregivers will document your care using traditional methods (handwritten or typed notes). You will continue to receive the same level and quality of care.

How to Opt Out

If you wish to opt out of AI-assisted documentation at any time:

1. Tell a staff member at your facility, or
2. Notify the facility administrator in writing, or
3. Contact CareTraceAI directly at privacy@caretrace.ai

Your request will be processed promptly, and your caregivers will be informed to use manual documentation methods for your care going forward.

Section 8: Questions and Contact Information

If you have any questions about CareTraceAI, this consent form, or how your information is handled, please reach out:

• Email: privacy@caretrace.ai
• Facility Administrator: (your facility will provide this contact)

You may request a copy of this consent form for your own records at any time.

Section 9: Consent and Signatures

By signing below, I confirm that:

• I have read this form (or had it read to me) and understand its contents.
• I have had the opportunity to ask questions and have received satisfactory answers.
• I understand that CareTraceAI uses artificial intelligence to assist with transcribing and organizing care documentation.
• I understand that all AI-generated notes are reviewed and approved by a caregiver before being saved.
• I understand that CareTraceAI is a documentation tool only and does not make medical decisions.
• I understand that my participation is voluntary and I may withdraw consent at any time without affecting the quality of my care.
• I consent to the use of CareTraceAI for documenting the care provided to the resident named below.

Resident Information

Signature of Resident or Legal Representative

Facility Representative

Revocation of Consent (complete only if withdrawing consent)

I hereby revoke my consentfor the use of CareTraceAI in documenting care for the resident named above. I understand that documentation already created and approved using CareTraceAI will remain in the resident’s record.

CareTraceAI — AI-Powered Voice Documentation for Better Care
Effective Date: April 9, 2026
Contact: privacy@caretrace.ai