Page 32 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

• 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 “red flags” to attorneys
who are reviewing the record for a potential malpractice suit.

Recent study results reinforce this concern. Reported in July
6
2018 by JAMA, the study comprised 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 two healthcare organizations

using Dragon Medical 360 | eScription (Nuance). It concluded
that “…Seven in 100 words in speech-recognition-generated

documents contain errors; many errors involve clinical
information. That most errors are corrected before notes are

signed demonstrates the importance of manual review, quality
assurance, and auditing.”

A disclaimer as to the accuracy of the note should never replace
a thorough review of the record. Some clinicians desire to warn

subsequent providers about the potential for inaccuracy when

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

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