Glossary of AI medical dictation and clinical documentation
The terms to know when choosing and using AI medical dictation software: health data hosting, document formats, modules and the vocabulary of artificial intelligence applied to clinical documentation.
Updated on 2026-10-05
- Medical dictation
- Voice recording in which a healthcare professional states the content of a medical document. With generative AI, dictating the clinical facts is enough: the software writes and structures the document. →
- Medical report
- Document describing a consultation, examination or procedure: reason for visit, history, clinical examination, conclusion, plan. It can be generated automatically from a dictation using a defined template. →
- Referral letter
- Letter addressed to a colleague or referring physician to pass on the conclusions of a consultation and the plan. In Eva Medical AI it can be produced together with the report, from the same dictation.
- Operative report
- Document written after surgery describing the indication, technique, findings and immediate outcome. Eva Medical AI offers a general operative format and an implant format.
- Medical certificate
- Attestation written by a practitioner stating a health condition or fitness. Built-in format in Eva Medical AI.
- EHR / EMR (electronic health record)
- Software managing the patient's record in a hospital or practice. Eva Medical AI does not replace the EHR: it focuses on writing documents and works alongside it.
- HDS (Hébergeur de Données de Santé)
- French certification granted to providers hosting personal health data on behalf of third parties. Eva Medical AI data is hosted on Google Cloud infrastructure in France whose provider is HDS-certified for the relevant scope. →
- GDPR
- General Data Protection Regulation, applicable in the European Union. It defines the obligations of the data controller (here Eva Medical AI) and the rights of individuals: access, rectification, erasure, portability, objection. →
- Template (document model)
- Structure of a report type: sections, order, level of detail, tone, mandatory mentions. Eva Medical AI provides built-in templates per profession and lets you create your own with the AI assistant.
- O'Zen
- Eva Medical AI module for long consultations: recording up to 1 hour, then automatic generation of a full report and a consultation summary. Included in the Premium plan. →
- Transcription
- Conversion of audio to text. In Eva Medical AI the audio is transcribed once, then a document is generated for each selected format.
- Generative AI
- Family of artificial intelligence models able to produce structured text from instructions and a source content, here the transcription of a dictation and a template.
- Speech recognition
- Technology that transcribes speech word for word. Unlike AI-structured dictation, it returns what was said without writing or organizing the document. →
- Ambient AI
- Approach where the tool listens to the whole consultation to produce a note. It requires informing the patient and respecting confidentiality obligations. →
- Clinician validation
- Mandatory step where the healthcare professional reviews, edits and approves the generated document before use, export or transfer. The clinician remains the author and responsible for the content.
- Encryption at rest and in transit
- Protection of stored data (at rest) and data exchanged over the network (in transit) with encryption algorithms. Applied to all Eva Medical AI data.