Page 33 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

examples of dictated notes entered into medical records without

thorough review:

 His headache began when you’re a goat (one year ago)

 The medical record had "heart replacement" but the patient

underwent a hip replacement

 Suspect purple muscular disease (peripheral vascular

disease)

 Will carefully monitor eyes and nose (I’s and O’s)

 History of sick as hell disease (sickle cell)

When the mistake affects patient care, it’s no laughing matter. You

are legally accountable for the accuracy of the information in your

notes and personal review of your entries in a timely fashion gives

you the opportunity to make any needed corrections. If you, or

other providers, are using inaccurately transcribed dictation, voice
recognition software or EHR entries to make medical decisions,

you may jeopardize patient safety. Transcription or software-

prepared entries which lack evidence of review by the provider

may serve as a “red flag” to attorneys who are reviewing the record

for a potential malpractice suit.

Study results reported July 2018 by JAMA Network Open of
6
“Analysis of Errors in Dictated Clinical Documents Assisted by

Speech Recognition Software and Professional Transcriptionists”

which collected a stratified random sample of 217 notes (83 office
notes, 75 discharge summaries, and 59 operative notes) dictated

by 144 physicians between January 1 and December 31, 2016, at 2

6 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2687052

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