Transcription expert warns risk managers about errors
Hold docs, transcribers responsible for their work
Risk managers may be unaware of just how sloppy and potentially dangerous their doctors’ notes are, says an expert in medical transcription services. Transcription professionals often see notes that would make a risk manager cringe, he says.
Though transcription professionals are accustomed to receiving confusing, error-filled notes from doctors, many risk managers are unfamiliar with the state of those notes before the transcriptionists work their magic, says George Heymont, owner of Alert & Oriented Medical Transcription Services in San Francisco.
He offers a word of warning to Healthcare Risk Management readers: "The people who transcribe are the equivalent of the maid who sees the rips in your underwear. It’s one of the dirty little secrets of medical information processing. A big problem is that risk managers don’t seem to be aware of this."
Transcriptionists aren’t doctors
Incoherent or confusing dictation from doctors is an annoyance to transcriptionists, but Heymont suggests it could be a serious liability risk for hospitals. Part of the problem is that doctors depend on a medical transcriptionists to make sense of their dictation and fix errors. The transcriptionists are trained professionals, but they are not doctors. Yet it has become standard practice for transcriptionists to correct what they know are errors in dictation, because that is what the doctors expect.
Heymont questions whether that is a safe practice for the hospital and doctor, who depend on the transcribed notes to be complete and accurate.
With so much transcribing outsourced, it’s out of sight and out of mind," he explains. "Risk managers don’t know what a liability they’re sitting on. We do what the doctors expect us to do, but I’m not so sure I’d be comfortable with the situation if I were a risk manager."
A twofold problem
Part of the problem involves non-physician transcriptionists taking responsibility for correcting what they believe to be errors in the dictation. While many doctors would object to the idea at face value, they also get upset if you give them a verbatim transcript that includes their obvious errors, Heymont says. But the other part of the problem involves dictation that includes errors missed by the transcriptionist or errors that the transcriptionist just could not figure out and therefore transcribed verbatim. Either way, the dictated notes are not the solid, reliable record of events that a risk manager would expect.
Poorly dictated notes come from all types of doctors, but Heymont says there is special concern with physicians for whom English is a second language. Even those who can speak English fluently may make errors in dictation. Many of those errors involve physicians who studied textbook English but have trouble adjusting to what people actually say in American hospi-tals a combination of American slang and medical slang.
"But it’s not just foreign doctors. Many American-born and trained doctors cannot make a coherent sentence," Heymont claims. "Each mistake can metastasize through the medical record until the patient dies from what is basically a word processing problem."
Although some mistakes are harmless even if they end up in the transcript, Heymont points out that those are the errors that are fairly easy to recognize. But what about errors that are ot so easy to spot? Mixing up "he" and "she" may be inconsequential, but the transcriptionist also could confuse similar-sounding drug names.
"The transcriptionist isn’t as likely to pick up on that, so it will get in the record," Heymont says. "That might be interesting if a plaintiff’s attorney is looking at the record."
Watch for pronoun errors, ambiguities
Heymont provides the following examples of actual dictation errors he has encountered:
• "The patient is a 48-year-old man who recently underwent a hysterectomy."
Dictated notes often include gender changes for the patient being discussed. With American doctors, it usually is the result of sloppy dictation. With foreign-trained doctors, the problem often can be traced to Asian languages in which pronouns are not gender-specific.
"When they speak English, they rotate the pronouns in every other sentence," Heymont says. "We get a lot of pregnant men and women with prostate problems."
American doctors may make the mistake in more subtle ways, calling the patient "Mrs. Smith" in one sentence and "he" later on.
• "Then I gave her three more sucks."
The physician meant that she administered suctional choline three more times. While "three more sucks" would have been understood in conversation, Heymont suggests that it does not look good on paper.
• "Patient POed this morning."
The phrase refers to the common abbreviation PO, meaning "per oral." The physician apparently meant that the patient ate that morning. Or did he? Heymont wasn’t quite sure, but he pointed out that POed is common slang meaning "pissed off." Should record indicate that the patient ate something or that he was upset this morning? If a plaintiff’s attorney is perusing the notes, the imprecise phrasing might be a red flag.
Poorly dictated notes should worry risk managers, says Linda Gobis, RN, FNP, JD, a nurse attorney with Kravit, Gess, Weber in Milwaukee. She knows of no cases that have resulted in litigation because of dictation errors, so the liability risk may be theoretical. Nevertheless, she says many risk management problems are theoretical until they happen at your hospital.
"I think problems with transcription are very widespread" Gobis says. "The worst result would be getting hit with a fraudulent medical record charge, but the more likely result would be not having a reliable record to use in your defense. The errors also could lead to problems with your billing and collections."
In addition, Gobis notes that health care facilities have a responsibility to preserve accurate medical records under regulations from the Joint Commission on the Accreditation of Healthcare Organizations and federal agencies.
Gobis confirms that it is very common for transcriptionists to correct what they think are obvious misstatements by the dictating physician. She suggests that risk managers need not see that as a bad practice, as long as the transcriptionist is experienced.
"But if the person is new and knows very little about terminology, that could be a disaster," she says. "You need to work with a transcription service that doesn’t give that kind of leeway to new people."
Some degree of "clean-up" is expected in transcription, but a line must be drawn somewhere, says Paul English Smith, JD, vice president for legal services and risk management at Cabell Huntington Hospital in Huntington, WV. No one wants records with every "uh," and "umm" transcribed, but an overeager transcriptionist can create serious problems.
If the problem is serious, albeit theoretical, what can be done? Gobis and Smith have three suggestions:
1. Hold the transcription service responsible for errors.
Contracts with outside transcription services should include an indemnification provision. If the transcription service creates an error in the document, even through trying to correct a dictated misstatement, the service should be held responsible for damages that result.
The transcription service may, in turn, ask for a clause absolving it of any damages from accurate transcription of misstatements. That would be a fair trade.
2. Hold physicians responsible for their notes.
Put a clause in your medical staff bylaws that requires physicians to review and correct any transcription. This puts the burden of accuracy back where it belongs, on the physicians. (See reader question, p. 118, for more on holding physicians responsible for dictated notes.)
To make the clause effective, you must give it some teeth for enforcement. Be sure to make this an administrative measure, rather than a clinical practice disciplinary measure, so you don’t have to report this action to the National Practitioner Data Bank.
3. Consider limiting the amount of clean-up done by transcriptionists.
At Smith’s facility, much of the transcription work is done in-house by hospital employees, but some is done by outside services. The outside transcriptionists are instructed to leave unknown material blank in the transcript and let the doctor fill it in. If the transcriptionists think they’ve gotten it right but aren’t sure, the hospital wants them to note that in an error report accompanying the transcript.
The in-house transcriptionists are more closely supervised and have the added benefit of helping each other with rough spots. ("What’s this sound like to you?") They are trusted with a bit more freedom to make corrections, but they still are discouraged from making corrections to any clinical information. Grammatical clean-up and correction of obvious errors in word choice are OK, but significant content cannot be changed.