I'm in the same boat now with the speech recoginition errors. I',m in multi specialty group practice. We have providers who include disclaimers such as: 1) as transcribed by voice recognition software 2) documentation elements generated by default template 3) chief complaint and vital signs may be imported from previous visit see intake note 4) " this was done with speech recognition I apologize for any typos/typographical errors 5) Dictated with voice recognition: I apologize for typos + wrong words 6) *THIS NOTE WAS TRANSCRIBED USING VOICE RECOGNITION SOFTWARE*
I took this to our risk manager/compliance officer and referred it to the Chief Medical Officer. It was brought to Clinical Informatics Committee (we do not have a Med Rec Committee). All agreed statements 2 and 3 should not be part of the documentation.!!! Statement 1,4,5,6 was thought to be a non issue "other providers in the communitity do it too"-we want others to know why there are mistakes, and blame the software, lack of time (true point-they are pressured to perform RVUs) etc. and I'm tasked with researching why this is an issue. The CMO was going to search the medical board. I stated if this is blown up in a court room and you have to testify.... Is this a "I did this note, I didn't proof read it and I don't care"? Risk Management is now researching this for me again - YEAH Ultimately the physician's signature is on the report ...but as Seth said can lead to troubles down the road Plus not to mention all the errors made and non standard abbreviations the providers are coming up with with completing their own templates. I'm trying to impress that we need Information Governance and compliance. The biggest fear the CMO has is he doesn't want policies because who would monitor it and enforce it. Sigh. Thanks!
Yes we are,
Seth Jeremy Katz MPH, RHIA Associate Administrator, Information Management Truman Medical Centers Hospital Hill Phone (816) 404-3355 | Lakewood Phone (816) 404-8505 | Fax (816) 404-3142 | Pager (816) 292-9024 | firstname.lastname@example.org Trumed.org |
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Due to the inherent limitations of voice recognition software, portions of the record may contain occasional wrong word or sound-a-like substitutions. Proofreading has been done to minimize errors. Please call if you need clarification or have questions.