Providers are legally accountable for the accuracy of the information in their notes, and personal review of entries in a timely fashion provides the opportunity to make any needed corrections. All notes and medical record entries should be reviewed for accuracy and properly authenticated (signed) by the provider. Inaccurately transcribed dictation, errors generated by voice recognition software, or other inconsistencies within an EHR note, report, or other document may jeopardize patient safety. Entries prepared by transcription or software which lack evidence of review by the provider may serve as a “red flag” to attorneys who are examining the record for a potential malpractice suit. At the very least, this failure to review transcribed or electronic entries will certainly give the appearance of lazy, sloppy, or indifferent care.
Disclaimers should not be used as they will not lessen the provider’s potential liability and will likely draw attention to the fact that the provider has not carefully reviewed his/her notes and is willing to accept any inaccuracies. Avoid using disclaimers such as: “Dictated but not read”, “Signed but not read”, or “Portions of the record may have been created with voice recognition software. Errors may have occurred...”.
Turnaround time for entries to be posted in the record should not exceed 48 hours, although 24 hours is ideal. This includes time allotted for review/proofing prior to posting. Delays past 48 hours may cause problems with patients who should be followed closely. With such patients, providers should create written notes and keep them until the transcription is in the record.
Should you have any questions, please contact an SVMIC Claims Attorney or the Risk Education Department at SVMIC by email at ContactSVMIC@svmic.com or at 800.342.2239.
