Signing note≠ Review or verification?

kayleeevans907

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Fairbanks, Alaska
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Hello,
I hope that I'm posting this in the correct section.
I am a coder at a physician's practice and recently noticed that one of our providers that uses software to dictate their notes from speech has a note that seems rather problematic, it reads:
"Portions of this note were generated using Dragon Naturally Speaking software. Dictation may not have been thoroughly reviewed."
Some fellow coworkers and myself think this would directly contradict a signature on the note as our understanding is the signature of the provider is to signify that they are taking responsibility for everything in that note.
There seems to be PLENTY of opinions on this but I'm hard pressed to find an actual guideline, law, etc. that would support why this auto-generating note might need to be changed.
Thank you
 

SharonCollachi

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Clovis, CA
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If they dictated it, they do not have to proofread it. I have seen that disclaimer many times. I read at least half of the charges the California Medical Board brings against physicians, and I have yet to see a single one have a problem with that statement.

I would change the second sentence to: "Unintentional errors in speech-to-text processing may have occurred", or something like that. That focuses more on the voice recognition errors rather than not reviewing the document.
 

thomas7331

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I agree. In my view, if the physician has signed the note, that is their attestation to the authorship of record - they cannot pass off the responsibility of any errors on the dictation software even with this disclaimer. If there are inaccuracies in the note, whether due to dictation software, typos, or for any other reason, it is still their responsibility. Making a statement such 'dictation may not have been thoroughly reviewed' does not tell us anything that would require us to assume that it has not been reviewed, nor does it alleviate the provider's responsibility for the accuracy of the content of the record.
 

tiaralady6466

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Palm Beach
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i have a provider that doesn't proof his op notes and never signs path or radiology tests prior to having them scanned to chart, where can I find guidelines to show him that he needs to show he has reviewed this info
thank you
 

Orthocoderpgu

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Salt Lake City, UT
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Maybe your doctor needs to be reminded that documentation is a "legal" document. All legal documents must be signed. If he does not sign and date path notes, there is no way to show that he viewed that documentation from a legal perspective.
 
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