Page 35 - Part Two Risk Reduction Series - Documentation

SVMIC Risk Reduction Series: Documentation

 “Portions of the record may have been created with voice

recognition software. Occasional wrong word or ‘sound-a-

like’ substitutions may have occurred due to the inherent
limitations of voice recognition software. Read the record

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 have it actually happened. It

likely does not accomplish much if there is a liability issue about

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 to catch any errors.

In any claim situation with an adverse outcome, any meaningful
charting errors are no longer innocent but become a detail 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.

From a patient care standpoint, the disclaimer may unintentionally
send the message to subsequent providers that the records

cannot be relied upon.

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