A community of 30,000 US Transcriptionist serving Medical Transcription Industry

disclaimers on medical reports - Terry

Posted: Feb 01, 2014

Has anyone heard of these types of disclaimers being placed on patient medical reports? "This is a computer-generated report - has not been read by dictating physician - may have errors". In other words, speech recognition reports eliminating the editing and putting it in the chart as is?

WOW! That's news to me. (NM) - NPC

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NM

Disclaimers - Not new

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Yes I have seen that and it was a couple of years ago and it wasn't even a VR report; a dictated report by the physician, stating it had not been proofread by the physician. So for all of those out there who think the hospitals/doctors care about the quality of their work, think again. Type away India and VR! We are history.

Before ASR - Nothing new

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Not necessarily un-edited. Just not read by the dictator before he signed it off.

Back in the day (before ASR, say late 1990's/early 2000s), on hospital progress notes we were to type a disclaimer: Dictated but not read. This just means the dictator signed it off without checking over for content.

This was even back when they had paper charts. Nothing new, if you ask me. We just don't physically type it in anymore. Could have something to do with ASR these days, I suppose, but it's nothing new.

You better belive I would raise holy H and threaten to sue if I were a patient who - saw that in my chart with errors. nm

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nm

On one account I - work on

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The normals all pull up "Unreviewed" on the bottom of the reports.

That is different - sm

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That is a reminder to the physician that he needs to review and edit them. When he does that, he can remove the word unreviewed.

That is the facilities' way of making the doctor aware of his responsibility. The use of normals, which contain text that might be wrong for some patients, is seriously frowned upon. It leads to the problem of the chief complaint being abdominal pain, while the ROS says no abdominal pain, blind folks having full visual fields, and amputees having 4 extremities.

Not new, but it is inappropriate - Liability

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Physicians do this hoping to avoid responsibility, but that is not possible. Once they sign it, they are responsible for the content of the report. Statements like that just add liability. Hospitals often prohibit them for that reason.

Back in the 90's I was hospitalized for 2 weeks (sm) - Rose

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I was not expected to survive and it had nothing to do with breasts or cancer, yet, according to the medical records, I had 16 breast exams during my stay! So doctors have not been able to manage their use of "normal's" as long as they have been dictating.

I find it interesting that they have finally realized that they are in danger of malpractice suits using ASR to the point that a disclaimer is becoming standard.

ASR does not cause the danger - It was there before

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You just pointed out that normals can lead to errors. You cited your own records from the '90s as evidence of this.

They have been using disclaimers for decades. It is nothing new with SR.

ASR Greatly Increases the Danger (sm) - Rose

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The errors on my records were caused by doctors who misuse normals, not by MTs who decide to throw in a breast exam here and there for a few extra lines. We have always had dictator errors, most caught by us. ASR likely doubles the errors that doctors have already made. Will malpractice insurance go up 50%? I wouldn't be surprised.

No, it does not - Again, you are speculating

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In your posts, you seem to make dogmatic and inflammatory statements like "ASR greatly increases the danger," which you then cannot back up.

In this case you start out with the above absolute statement, but follow it with what you just kind of imagine is true. In the post you change it to say "ASR *likely doubles* the errors that doctors have already made." (emphasis mine)

So, it isn't definite, as you indicate in the subject, and it turns out that you are just using your imagination.

Very misleading.

To [anonymous] (sm) - Rose

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I speak from experience editing ASR reports. ASR claimed the patient had a "circus-sized penis" yet you call me inflammatory?? I do know that ASR greatly increases the danger of erroneous information going to the patient's record because you treated my report that I was given 16 breast exams in one hospital stay like it was breaking news, an admission that there were errors before ASR. Well duh! There have always been errors. That does not mean that our personal medical records should be treated with total disregard for accuracy at the risk of harming patients! I have corrected countless errors in medication dosages that could kill a patient. Are you saying that is okay, because doctors have always had dictation errors?

Wow, Rose! - sm

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That's a lot of breast exams in one day. Hee-hee! And nowadays I can't think of any medical condition for which insurance would allow a 2-week stay. Hope you got taken care of in that long period of time!

Thanks. (sm) - Rose

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It was over a 2 week period, but still, I had to laugh at getting breast exams when I wasn't expected to life. What was the purpose, finish me off faster with chemo if they found something?? lol.

Get copies - Oldie

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I tell everyone I know to get copies of their records and if there are mistakes on mine, I ask for them to be corrected and they have been.

Liability - Nick

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You are right. In the law, it is called the doctrine of Captain of the Ship.

Yes, I have had those disclaimers before - sm

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On an ASR account, I had one physician who always put in a "standard disclaimer." I can't remember exactly how it went, but it basically said that "this report has been computer-generated and as such, it may contain errors, inconsistencies and extraneous words that have not been dictated by nor approved by this physician."

nothing new - recycled cya

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Years ago every report generated at some of the hospitals I worked for said something similar to "Signed but not read" and those were generated by MT.

The reality is, when you're getting crap and a lot of the work produced by an MT is crap, then why not pay less and realize crap is part of the process.

I cringe reading what some of the other transcriptionists put in reports for my account. It's embarrassing. So all this up in arms over VR making errors, IMO, is stupid when you have an MT making errors too.

I remember - see msg pls

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...back in the good ol' days when this job paid well and there was no ASR, I was in the QA Department of what was, at the time, the biggest national transcription company.

I had no clue how bad the MTs were until I entered the QA Dept. Unbelievable errors, really, really stupid ones that anyone with half a brain would never type.

Not typos, not ASR or dictator errors. I'm talking about common sense, like doing a catheterization procedure and typing "castration" procedure. You don't have to have taken so much as a medical terminology course to know that one. And if you don't know what castration is, then you shouldn't be walking the face of the earth.

That wasn't even the dumbest one I ran into. And the company let these people transcribe. Nobody ever got fired - at least not back then. They just kept putting them back on full QA, and I kept fixing their messes, year after year

I was paid $22 an hour at the time, so that part was fine, but we weren't allowed to "scold" the MT, or we got in deep stuff with our supervisor. Fast forward, ASR came out, even worse crud being in the report, unfixed, and they changed us from hourly rate to production line rate. That was it for me mentally. I stayed on for a few years, and finally got out of MT totally, 2 years ago.

Those were the days... (sm) - Rose

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When ICs could turn down MTSOs offers. There was no way I would transcribe for them for just .07 cents a line. That's because I charged .12 and .14 CPL from my clients who I had for decades. So the MTSO were forced to use newbies. Nothing against newbies, but they are not qualified to work on their own without several years experience and working for .07 CPL for a service was a great way to get experience in many different specialties.

I highly suspect that the person on this thread who is reporting MT errors is referring to the olden days where services had MTs who needed the experience. I think today they have the cream of the crop.

A few questions... (sm) - Rose

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Regarding your statement: "I cringe reading what some of the other transcriptionists put in reports for my account"

Did you hear the audio?
Does the service allow blanks?
Is the MT penalized for sending to QA?
Was this report edited by the client?
Does the service hire newbies?

I frequently looked at previous reports to accurately research dictation errors on about 40% of all dictations (free labor). The transcription that I see today is near perfect, in fact I have only seen one error in the last year. It is not fair to blame the MT for dictation errors and not look at the true source of the errors. If an MT does not have 99% accuracy, there are hundreds out there to take her place. If you are a client, and your claims are true, I suggest you find a different service or hire an MT to do the work directly without the middleman.

seriously? - SM

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Did you hear the audio? No need to.
Does the service allow blanks? Yes.
Is the MT penalized for sending to QA? No.
Was this report edited by the client? No.
Does the service hire newbies? No.

"I'medical not feeling well today."

"Tobacco sensation."

Errors that show shoddy MT work for which there is NO reason and NO excuse. You want to complain about your records, Rose, and the errors and yet your questions intimate that you find "excuses" that make some errors okay.

Crappy MTs are a big factor in why we are where we are today mixed in with greed. If you're going to pay for crap, well then you aren't going to pay top dollar for it.

You hit the nail on the head - sm

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I think you hit the nail on the head . .. transcribed documentation has always been full of errors. I know that most of you won't believe it, but it is true.

It has nothing to do with how much experience the MT has, either. When they start out typing nonsense, they typically keep on typing nonsense. There is no way to fix it, either, because they have no insight into their problem. In other words, they all think their work is perfect, right down to the bologna amputation. (Or, as the MT at our former MTSO spelled it, baloney amputation.)

There really isn't much difference between work produced by MTs and SR. However, we find that front-end SR is an improvement because the doctor does edit the critical items. Since the transcript is appearing in front of his eyes, he can do that. It may be messier, yes, but we no longer have bologna amputations.

The doctors do get the hang of this, too. Our cardiologists use a high-end integrated system in the cath lab that handles everything from soup to nuts. The end reports now read perfectly and the report is available instantly.

I suspect you are replying to your own comments (sm) - Rose

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As I can't believe there would be more than one person on an MT forum who has such low regard for MTs. I also think that your claim: "transcribed documentation has always been full of errors" and "there really isn't much difference between work produced by MTs and SR" makes me doubt you are an MT.

I was an MT for years & I am not - responding to my own posts

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I worked for services and hospitals, locally and nationally. Doing that, I saw what other MTs did. We often had physicians bring us documents and complain about the errors.

Now, at another hospital, I daily see MANY reports from several MTSOs that contain errors so bad that I would be unable to figure them out if I had not been an MT. Our coders ask if I have any clue what they mean. These aren't spelling and grammar, but things like ... literally ... "baloney" for below-knee and "hemorrhoidic" for hemorrhagic. It is absolutely clear that these are NOT ASR, but actual MT-transcribed reports because the errors are often phonetic guesses like "urthal" for urethral, "farngal" for pharyngeal, and "poputial" for popliteal.

And, no, these horrors do not come from newbies. At one hospital, they were perpetrated by two 20-year veterans. Now, the services insist that their MTs are not only experienced, but reviewed by editors. We dumped one service after they insisted that we didn't know what were were talking about ... if their MT said it was a "fleaplastiky" instead of a Z-plasty, or a "currinary artery, then that was what it was.

Truly, the errors our doctors produce typing it themselves aren't any worse. What they produce using front-end SR is far better.

No, I'm the person to whom she is responding - and

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you're a joke. One of the Mts who likely doesn't even realize she's a joke.

I've been in this field a long time and have hired and trained MTs and sometimes people are simply lacking in ability. Sadly, in my current situation, all I can do is report the errors. I wish I could fire them because I don't want them jeopardizing my job.

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