Proofread your dictations!
Ok, I've had it. I am constantly reading notes from nurse practitioners, physicians, and other psychologists that were dictated. To those who are unfamiliar, many health professionals dictate their notes into a recording device. The recording is later translated into a note in the hospital computer system. The health care provider then gets an email to proofread the note, accept it, and finalize it. If it is not finalized, the person who dictated the note can get in trouble.
As you might imagine, the people typing the dictations are not physicians. They have taken some classes about medical terminology but they cannot understand every word spoken, especially with the high number of residents that do not speak English as their primary language of who have a thick accent. So the person preparing the dictation often puts a line like this: _______ to represent words that were not dictated. The person who dictated the note is supposed to go through the note and fill in the blanks.
Every day, I come across notes that were finalized but still have blank lines in them. This clearly shows that the person did not actually proofread the note and only finalized it to avoid getting a nasty gram from the hospital. I once heard a health care provider say "I don't have time to read them anymore. I just finalize them and hope they got it right." Excuse me, but… WHAT?! If you don't have the time to proofread the note, it is time to see less patients. The medical record is a crucial piece of information that when it is not proofread and is left with either incomplete or incorrect information, it diminishes the ability of other providers to fully understand the case. This is poor practice.
Are my reports mistake free? No. That's impossible. But when a mistake is found, I know I can tell myself as much as is reasonably possible to prevent one. That is, I write all my own notes and never dictate, I read the report once on the computer, and then I read I again after I print it out on paper. Overkill? Nope. I always find something to correct on both versions I proofread.
My end message: Please take the time to proofread the reports of your patients. It is the final product of the visit and is a permanent record. The patients are relying on you. Don't let them down.
posted by MedFriendly | 12:22 AM
3 Comments:
I would review nurses notes at my facility and the lack of documentation is high. We would always say," take credit for what you did", but due to high patient load, sometimes alot would be missing. Anyway one has always stuck in my mind. It was a one liner that stated " Pt. c/o SOB MD called"- but no S.O.B, no sx, and it looked like the patient didn't like his doctor much. :) Have a great day. JP
I could kiss you. Being a transcriptionist, we deal with this daily. There are some dictations that are so horrible, they are nearly unintelligible. Most of us can not and will not take on the responsibility of guessing at what a doctor is trying to say. So many dictate in the car, in the middle of a busy cafeteria, on a cell phone with bad reception, or they whisper because they don't want someone to overhear them. All these interferences and more can lead to holes in a dictation. It is scary to think that the practitioners who dictated those notes couldn't be bothered to review and fill in the blanks.
I am also surprised that these notes would fly with the quality/utilization review departments at the hospital, as blanks in reports could lead to a lack of reimbursement. After all, why should an insurance company or Medicare pay on a claim when the information they need isn't there?
Thank you for taking the time to address this issue.
One thing I would like to point out, though, is that about 80% to 90% of the transcriptionists I know have more than taken a class in terminology. (See this blog: http://mttalesfromthescript.blogspot.com/2007/10/those-stupid-transcriptionists.html)
Some of us have bachelor degrees, masters degrees, and even doctoral degrees. We have chosen transcription because it suits our lifestyle at the moment. We are not unintelligent or uneducated, and we care as much about the patient's well being as anyone. Unfortunately, some employers and hospitals are making transcription less about patient care and more about the all mighty dollar. They will get what they pay for.
Again, thank you for taking the time to bring this issue to the forefront. If it will change even one person's method of signing off on reports with blanks, it will make it worthwhile.
Great post. These transcribed notes will take on even more importance as EMRs take hold. During a recent webinar on Healthcare Trends for 2008, Dr. Joel Diamond talked about the promise of voice recognition software for improving patient care: "A year ago or earlier, if you had asked me about voice recognition, I would have said that I was totally against it because voice recognition to date is really the same as transcription or writing...One of the reasons I’ve come full circle on this is that free text allows physicians to work faster. Because of that, there is a higher adoption rate of EMRs. We’re in a race, and that is why we have to get as many doctors using EMRs as possible. If voice recognition allows us to do that, then that would be great...If we can get physicians to use this technology in a meaningful way and get them to focus on the present illness or the assessment plan, then we could do well. Doctors ask me what to extract from these EMRs. There are several examples that I use...A few years ago when Vioxx® was recalled, it was the first time in my professional life that I just went to the computer and typed in the word ‘Vioxx’ and got a printout with the name of every single patient for whom I had prescribed the drug. In fact, I saw several patients for whom I had never written a single prescription for Vioxx but had just handed out samples to those patients. This was an incredibly useful tool for notifying those patients and informing them of what had happened. Without an EMR, I probably would have waited until they came to see me because there would be no way of auditing those charts. Similarly, had I free-texted those charts, I probably wouldn’t have been able to get at it as well." Visit http://www.hin.com for more of Dr. Diamond's comments.
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