
There Are No Words
Posted on July 13, 2015 in Healthcare

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.
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