Medical Transcript Accuracy

[Level_II_Trauma]

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These are general questions for anyone wanting to answer.

How dependent is your patient care (as their medical provider) upon what is transcribed in their medical record?

Do you base your treatment upon what is transcribed in their record, or do you use other substantiating information? If a medication name, dosage, or lab value was transcribed incorrectly, would this be a factor in your assessment/treatment of this patient, or do you use other references for validity?

I guess what I'm asking is, how much, if any, of the patient's care is affected by the actual transcribed report? Do you know of any examples where a patient's care was adversely affected by something transcribed in error?

Many times a doctor's dictation can contain errors here and there for whatever reason. Doctors aren't machines and can't be expected to perform like them. However, with so many transcriptionists being required to transcribe only verbatim what is dictated, there are times when errors can be entered into the chart via the records they produce.

What do most doctors prefer, that their words are transcribed verbatim, exactly as dictated, or do you prefer to have inconsistencies and/or inadvertent errors (such as dosages and/or medication names) be brought to your attention?

And mostly, I would like to know, how much weight is placed on the transcribed document as it pertains to patient care?


Thanks in advance for any insight you can provide from your standpoint.

 

[Hurricane]

And mostly, I would like to know, how much weight is placed on the transcribed document as it pertains to patient care?

Depends on the patient. If it's an altered mental status patient and I can't get a history except for what I can find in the computer, I give it more weight. But most of the time I use it as a guide for when I am obtaining past medical history and medications during my interview to make sure I get everything. As in:

"And do you have any other medical problems?"
"Just my arthritis."
"Well, I saw in your records you're taking Toprol, what's that for?"
"Oh yeah, I had heart surgery 4 years ago... etc.

 

[sdn1977]

hmmmm....yeah...transcription errors - abundant!!!! as well as those continually rewritten orders when transferring from one level of care to another:

My mom - tx from acute inpt orthopedic surgery to rehab ortho...same hospital (altho diferent entities, I realize...) - it required a completely new chart! In transcribing the medications (I'm a pharmacist, so I was particularly interested)....her atenolol was transcribed as 100mcg/d (that was supposed to be levothyroxine). The levothyroxine was transcribed as 50mg bid - ooops - should have been atenolol). The HCTZ was dropped - not deliberately and a new "allergy" was added - codeine: Why???? someone thought her postop vomiting was due to the hydrocodone/apap or ms...so they decided she was codeine allergic - UUUUghhhh! The vomiting was probably due to anesthesia &/or her partial hip replacement!! No one asked her🙁 .

Thank goodness she made it out of there! I have to say...the surgeon & all nursing & therapy staffs were great...but the bureaucracy which JCAHO has generated is monumental!!!!! And I work with it - makes it even worse seeing it from both sides.

 

[radonc]

as a physician, there is no room for error. documentation (and accurate documentation) is key. you never know when someone will come back and sue you.

 

[Level_II_Trauma]

hmmmm....yeah...transcription errors - abundant!!!!

her atenolol was transcribed as 100mcg/d (that was supposed to be levothyroxine). The levothyroxine was transcribed as 50mg bid - ooops - should have been atenolol). The HCTZ was dropped - not deliberately and a new "allergy" was added - codeine: Why????

🙁 I wonder if indeed these med dosages were transcribed in error or if they were dictated that way in error, perhaps had even been written in the chart that way?

I agree with you though, what a mess and especially when it pertains your own mother. Do you think it was just sloppy transcription or sloppy chart-handling altogether? Maybe too many fingers in the pie?

 

[Level_II_Trauma]

as a physician, there is no room for error. documentation (and accurate documentation) is key. you never know when someone will come back and sue you.

So, as a physician, if you mistakenly dictate male vs. female, or right vs. left, or mistakenly dictate BUN twice in the same set of labs as two different values (maybe you just inadvertently said BUN two times instead of BUN and creatinine, for example), or any other number of possibilities, do you want that inconsistency brought to your attention by your staff and/or transcription service? (Especially with the trend now being that transcription is done off-site, even overseas, potential errors become harder and harder to bring to the physician's attention. If a transcriptionist doing your work over in India doesn't point out the error the moment he/she notices it, it's entirely probable that you're not going to know about it, either, unless you're reading word-for-word everything you have dictated before you sign off on it.)

 

[Level_II_Trauma]

Thanks Hurricane for your answer. That's helpful for me to know.

 

[radonc]

So, as a physician, if you mistakenly dictate male vs. female, or right vs. left, or mistakenly dictate BUN twice in the same set of labs as two different values (maybe you just inadvertently said BUN two times instead of BUN and creatinine, for example), or any other number of possibilities, do you want that inconsistency brought to your attention by your staff and/or transcription service? (Especially with the trend now being that transcription is done off-site, even overseas, potential errors become harder and harder to bring to the physician's attention. If a transcriptionist doing your work over in India doesn't point out the error the moment he/she notices it, it's entirely probable that you're not going to know about it, either, unless you're reading word-for-word everything you have dictated before you sign off on it.)

yes i w ould.

i scrutinize each of my dictations before sending it to the attending for their approval. not only do i scrutinize it for mistakes, but also to make sure it included items that make it a level 4/5 consult or follow-up which we routinely bill...in case we get audited. it doesnt take that much more time to look through dictations. and i do about 20-30/week.

if you are organized prior to starting your dictations, it makes it a whole lot easier. then, you develop a routine (for the most part is good) and things flow nicely.

 

[sdn1977]

🙁 I wonder if indeed these med dosages were transcribed in error or if they were dictated that way in error, perhaps had even been written in the chart that way?

I agree with you though, what a mess and especially when it pertains your own mother. Do you think it was just sloppy transcription or sloppy chart-handling altogether? Maybe too many fingers in the pie?

Actually, it was multifactoral. I saw the ER record - the drugs were written down exactly how she said them with a knowledgable family member nearby (me😀 ) by the RN. The ER physician reviewed them verbally as well.

However...in passing off to the ortho service & the inpt hospitalist...the drugs & doses changed (& so did family - I left for my daughter's white coat ceremony & another sister came). When I came back...she was in rehab...the inpt hospitalist & chart long gone....& the PMR dude knows nothing except what was given to him.

Her course was rapid & uneventful...so required very little change - which was why I'm curious 2 antihypertensives & a diuretic was dropped & the beta blocker & thyroid medication doses were halved.

Whatever...we watch ankles, monitor bp's & get an appt w/ the primary next week......however...she was asked twice (TWICE) if she could perhaps be pregnant (she's 87....😕 ). The folks shuffling the papers have the emphasis on the wrong paragraph apparently. There is far too much paper to shuffle & the important stuff gets pushed back.

However...seriously...how many of these same folks who don't have family that is knowledgable may suffer a consequence of these mishaps (or not - still don't know) & need to be readmitted????

As a pharmacist...that was a reason I left full time hospital work. We no longer followed pts medications daily & did discharge counseling. My mom had NO medication discharge counseling - other than the nurse saying here's your rx for Norco. (I aplogize for the hijack & the rant....🙁 ).

 

[Level_II_Trauma]

Not a hijack and not a rant. I'm interested in all aspects of how charts are handled / mishandled and how it affects patient care.

From a transcriptionist's point of view, we sometimes never know whether what we type is even read or if it matters. This is what prompted my original question. It's also important from our aspect to know whether we need to bring up a discrepancy to a doctor dictating. Doc's get tired, they repeat the same stuff over and over, and for any number of reasons, something can be dictated in error. I remember a resident just rattling off so fast the words he had said so many times, that in this particular case, I just had to go and grab him and shake him. He dictated "The patient was discharged to the morgue for further evaluation and treatment." If we, the transcriptionists, were simple machine/robots, that's what you would get for the text in your report. Same goes for Voice Recognition software. If you say it, that's what you get. I think it's vital that we, as living, breathing human beings, are able to jump up and intervene,as we are able to differentiate between what makes sense and what doesn 't, be it a common phrase or a common dosage (even though we're not pharmacists, but after awhile, we tend to remember that 5 mg of morphine is probably correct, where 50 mg isn't).

In the dictated example I used above, I can only thank someone above that I worked right alongside this particular resident in the ER and had the ability to bring it up to him face-to-face. To think that this record might have been transcribed off shore over in India, or even on Voice Recognition software...how the heck is that gonna look on a record in a patient's chart? Think if the family got a hold of that record and saw that their dearly departed had gone to the morgue for more evaluation and treatment after being pronounced. 😱

I just want to say thanks again for all who have given some input here in this thread. It helps me immensely to remember I do play an important part when it comes to patient care, even if it's only to make sure the right stuff gets put down on paper.

 

[Nerdoscience]

Some transcription booboos that I have seen this month:

-Spinal cord injury in a brown, scarred pattern (should be Brown Sequard)
-IV Salmeterol for his GI inflammation (should be SoluMedrol)
-Apply Lovenox cream bid (should be Dovonex)

 

[fistulitis]

It's probably safest if the transcriptionist does NOT make any executive decisions about what the dictating physician actually meant to say.

As far as contacting the physician, go for it if you want, though most of them would probably be surprised to hear from you, if not pissed about the extra phone call / time use.

After all, one is supposed to proof-read typed dictations before signing them (whether electronically or otherwise).

 

[Level_II_Trauma]

Some transcription booboos that I have seen this month:

-Spinal cord injury in a brown, scarred pattern (should be Brown Sequard)
-IV Salmeterol for his GI inflammation (should be SoluMedrol)
-Apply Lovenox cream bid (should be Dovonex)

Darn good thing you're checking those reports. Not all (or even most) transcriptionists would try and squeeze by with stuff like that. It really depends if you've got a newbie doing your reports or not. I don't know why some would rather throw anything in a report than just admit that they don't know what you're talking about and ask. Transcription isn't just typing a bunch of medical words real fast, even though some seem to think that's all required. A seasoned transcriptionist is going to know (sometimes before you even dictate it) basically everything that you want in your report, from the meds, to the dosages, to the expanded name of every abbreviated diagnosis, the systems review, the normal and abnormal ranges of lab values. These are the people who you should take a moment to listen to when they bring up a discrepancy in your report. They're covering your back and are trying to get you to look as professional as possible on paper.


Now I think it's time to go take my Dulcolax subcu. LOL. 😉

 

[CasaElGato]

Thank goodness I'm at a program where I never have to dictate. Ever!

 

[Hurricane]

One of our residents did her first dictation, and at the end, she said something like "I'm sorry if this dictation was really bad, I've never done this before" and the transcriptionist duly transcribed it, word for word.

 

[Level_II_Trauma]

One of our residents did her first dictation, and at the end, she said something like "I'm sorry if this dictation was really bad, I've never done this before" and the transcriptionist duly transcribed it, word for word.

You should have kicked that report right back to the service/transcriptionist with a firm boot. You're paying for a product which meets medicolegal requirements, and a "transcriptionist" who cannot discern between what part of your dictation belongs in the report and what part is extraneous has no business being part of your loop, no matter how remote he/she is.

You'll find this kind of subpar transcription with outsourced work done overseas, where English is not the primary language. You'll also find it with voice recognition software. You may even run across the lowly service here in the US which does not screen its employees thoroughly enough before putting one of them behind the wheel. Either way, a trained professional who has dedicated as much time, effort, and money into their career as a doctor deserves an outstanding quality product for the amount of money that must be paid out for transcription. It's not cheap and it shouldn't be. A lot of us have been doing this longer than many of you have been in the medical field. Some of you (maybe even most) were still in diapers when we started transcribing. We have the utmost respect for you and believe you deserve the very best. That's why it's saddening to see a lot of facilities going for the outsourcing, or the voice recognition software. In the end, you get what you pay for.

Just as a side note, here are actual excerpts from some reports generated through voice recognition, and one which was outsourced to India.

From Voice Recognition:

- The patient had seborrheic dermatitis, which cleared with the use of Sister Mary Greene. (Should have been "a steroid cream".)


- HEENT: He has mild moon asses. (Instead of mild moon "facies".)


- Hi, this is Dr. xxx dictating constipation. (Should have been "consultation".)


- She was exercising vaginally in her aerobics class. (Should have been "vigorously".)


- The patient's has-been is at her bedside.


- HISTORY OF THE PENIS: (PRESENT ILLNESS)


- The patient presents with grandma's seizure.

And one from India:

- Cereal CT scans showed.......



I could go on and on...but I guess you get my drift. 😡