There Are No Words

The following disclaimer was noted in a patient’s electronic health record: 

"PLEASE NOTE:  Voice recognition software was used in completion of this document.  There may be multiple grammatical and punctuation errors, improper verb tenses, misspellings, and gender designation. "

WHAT!  This disclaimer of sorts only superficially scratches the surface!  The sad reality is many critical errors—those with potential to cause patient harm—go unchecked in voice recognition, including a wrong diagnosis, an incorrect medication or dosage, or a significant omission.  Non-critical errors—those impacting document integrity but not serious enough to potentially harm a patient—also remain in the patient’s legal medical record without correction. 

The International Journal of Healthcare Quality Assurance (IJHQA) recently completed a study to quantify the number of errors made in physician dictation of patient medical records, revealing that, on average, greater than 30% of patient medical records contain errors.  One million dictations were studied with 315,000 errors flagged.  Those numbers are certainly a convincing argument for the critical need to ensure quality assurance is a part of the workflow.  Opti-Script recently sponsored a contest for our editing team to initiate ongoing “Speech Wrecks” for our website, demonstrating the critical need for quality assurance by experienced healthcare documentation specialists.  In five days, 18 single-spaced pages of speech errors were collected—all with either the potential to harm the patient or impacting integrity of the encounter record.  And that’s just the beginning.  Without a quality assurance function, those errors go unchecked—and patient care and reimbursement are at risk.