Wiki Disclaimer for typographical errors??

jenboyer

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We are using Dragon speech recognition software to dictate in our EMR. There are sometimes typographical errors. One physician has begun to include a disclaimer of sorts at the conclusion of his note stating: "Note is dictated utilizing voice recognition software. Unfortunately this leads to occasional typographical errors. I apologize in advance if the situation occurs. If questions occur please do not hesitate to call our office". Does anyone have any thoughts/opinions regarding the appropriateness of this disclaimer?
 
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When your provider appends his signature to any patient operative or progress note, he is authenticating it's completeness and accuracy. A disclaimer will not help him in court if there's an error in Dragonspeech that indicates athero when it should have been arthro or ortho. See my point?

Small errors like "you're" instead of "your" may be irrelevant with regards to patient care, but they certainly make your provider look like he might not understand English. And if consultation notes are headed to another provider's office, I am assuming he'd want his note to be as correct and professional as possible.

Dragonspeech can be taught to understand regional or foreign accents. He just has to retrain his Dragon.
 
I have providers that use dragon speech as well and they also use a disclaimer. I've noticed some providers will say "he" and then a couple sentences later it will say "she". The patient is a male and only one time it will say "she". I feel that the note needs to have the correct gender especially if the note has to go to court because then it may look like did the provider see this patient since it says "he" and then "she".

I am wondering if anyone has industry standards for dragon speech and if you feel that the note needs to be corrected?
 
IMO, it goes to credibility of the provider. I handle a lot of legal cases and have seen the he/she gender issue cast doubt on the veracity of the documentation. One or two clear typo errors, if not in the context of an objective clinical finding are not a significant issue, but if there are more than a few and the context of the opinion can be questioned, then the whole record is suspect. I see this especially with templates or cloned notes where CC differs from HPI which differs from ROS and then the diagnosis or assessment and POC do not make logical sense. I had a case today where the HPI noted physical therapy was effective in reducing pain and improving ADL's. Then the assessment noted failed physical therapy with recommendation for pain management due to radiculopathy, but the physical exam was entirely normal with no objective radiculopathy findings.
 
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