Page 33 - Risk Reduction Series - Documentation Essentials (Part Two)

SVMIC Risk Reduction Series: Documentation Essentials

using speech recognition software or other engine-generated

transcription tools by including a “disclaimer” with the note such
as:

• “Dictated but not read”

• “Signed but not read”

• “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 or 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 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. Such a

disclaimer could potentially 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 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.

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