Page 22 - Part 2 Navigating Electronic Media in a Healthcare Setting

SVMIC Navigating Electronic Media in a Healthcare Setting

carefully to identify, using context, where substitutions may
have occurred.”

However, disclaimers do not lessen risk and do not alleviate the
physician from his or her responsibility to assure the accuracy of

the note in a timely fashion. If anything, a disclaimer may draw

attention to the fact that this might not be how it actually
happened. It likely does not accomplish much if there is a liability

issue regarding erroneous documentation. The physician still has

to explain why the error was not caught. Potentially, such a
disclaimer could be used against the physician as an

acknowledgment that he or she is already aware that what is
being entered into the record might be inaccurate due to the EHR

itself or voice recognition software; but the physician is not
thoroughly reviewing the record to catch any errors. In any claim

situation with an adverse outcome, any meaningful charting errors

are no longer innocent and become details that allegedly caused
harm. If a physician is aware that errors from the voice recognition

software or EHR are common, then there could be a need to find a

different system or simply review the documentation with more
detail. A disclaimer as to the accuracy of the note should never

replace a thorough review of the record. From a patient care
standpoint, the disclaimer may unintentionally send the message

to subsequent providers that the records cannot be relied upon.

The Use of Scribes to Document the EHR

With an increasing documentation burden, some practices have

begun using scribes as a cost-effective and efficient way to help
providers spend more time focusing on patients. A scribe is an

extension of the provider, and it takes time and effort to train

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