Su
2004-09-10 18:12:53 UTC
Regarding the issue of putting any type of disclaimer at the bottom of a
medical report ... This was in a VR forum, but I feel it can apply to *any*
disclaimer:
Author: equine chiropractor
Date: 08-30-04 15:50
I am using NaturallySpeaking to dictate chart notes. I have seen several
disclaimers placed at the end of chart notes by other physicians. I was
wondering if anyone knows if there is a 'best' disclaimer, or if the
following is adequate.
" Note: this chart I was prepared using voice-recognition software and may
contain unintended word substitution errors."
I appreciate any replies
What appears below are two responses from a legal standpoint. I think it's
something that needs to be given due consideration
Author: Richards
Date: 08-30-04 22:41
Gentleman -- I AM a lawyer, and, although I no longer do injury work, I once
did, and am even more adamant than TechMD or Larry K. against the use of
so-called "disclaimers" -- for much of the same reasons they give.
A doctor is held to a high punctilio of precision, especially when a
typographical error compromises the quality of medical treatment received by
the patient. Putting such a disclaimer provides NO SAFETY. It merely
indicates you are 1) unwilling to proofread your work, 2) that you think a
disclaimer excuses your largess, and 3) are indifferent to the quality of
care your patient receives. This is an unequivocal indication you will
tolerate errors, and think explaining how they happen makes it OK.
Of course, this only matters if the patient is injured or patient care is
compromised by the transcription error. If there is no harm, there is no
foul...
My favorite medical speak-a-graphical error goes as follows (say it out
loud, and you'll see how easy this mistake can occur):
Podiatrist says = patient presents an acute Tedis Pedis...
DNS Types = patient presents a cute tiny penis...
So, do you think that your patient will think it is okay that your computer
made a mistake? Do you think your "disclaimer" will assuage his
embarrassment to any substantial degree?
You are responsible for the consequences of your errors whenever they
compromise patient care or lead to patient injury, regarless of whether or
not your transcription system (human or otherwise) is blame by
failingcorrectly transcribe what you dictated. The jury won't care whether
YOU made the mistake, yourself; your transcriptionist made the mistake; or
your dumb old computer made the mistake -- anyway you slice it, YOU will be
held responsible (i.e., liable) for the adverse consequences of any mistake
that yields untoward consequences.
Therefore, I wish to reinforce everything Larry and TechMD said, and the
very tone in which they said it.
So... having said that... please disregard any speak-o-graphical errors you
might find in this reply, because I am using experimental voice recognition
software ....
Happy trails to you all!
NB -- [Construe all these replies as a respectful and serious response to a
very important question. This could be a matter of life and death, and such
issues are what we call in my business, a potential "career-stopper." The
fact we weigh in so strongly merely reflects how important the underlying
question really is.]
Best Regards /// Richards ///
===================================
Author: techemd
Date: 08-31-04 09:35
Steve,
I respect your position and have heard it a number of times. The "speed with
which you lept to the opposite conclusion--broad brush in hand--" came after
working as a physician and in medical malpractice defense fro the past 18
years.
I called some attorney contacts I have on BOTH sides of the courtroom (just
to get THEIR take on the situation). The defense attoneys I contacted DON'T
want the disclaimer anywhere on the note. The plantiff attorneys I contacted
LOVED the idea and then proceeded to tell me how they would "rip the author
of those notes to shreds" EVEN IF NO ERRORS WERE FOUND IN THE NOTE! They had
some rather interesting approaches on how to discredit the author simply due
to the presence of a disclaimer on a medical note.
The attorney's I contacted couldn't agree with Richards more....Thanks!
In terms of the "broad brush"....well, I was only speaking about the
original question which was a disclaimer on a note written on a medical
record...a very specific place.
I have to add my personal favorite:
"The patient presented with a complaint of trouble breeding" (actually what
was meant was "...trouble breathing." This was NOT a mistake of voice
recognition but rather an actually typed error by a transcriptionist and if
you notice breeding is spelled correctly as well...not all the mistakes
transcriptionist make are spelling typos. I've got hundreds of them...all
spelled correctly.
One last thought....as Richards also eluded to....please accept my comments
as "a respectful and serious response". I do not wish to offend anyone or
anyones opinion but rather to help Ken from making what at least every
attorney I spoke to from making a mistake when it comes to documenting in a
medical chart.
Scott
(Disclaimer: I was tired when I typed this, the lighting wasn't good, I was
interupted constantly and I didn't proofread anything so their could be some
mistakes I didn't intend to make. I'll decide later what I meant to say if I
get in trouble.) --please take that as a joke.
If you wish to read the remaining messages on this subject, you can click on
this link:
http://s103536049.onlinehome.us/knowbrainer.com/forum/read.php?f=2&i=10732&t=10732#reply_10732
medical report ... This was in a VR forum, but I feel it can apply to *any*
disclaimer:
Author: equine chiropractor
Date: 08-30-04 15:50
I am using NaturallySpeaking to dictate chart notes. I have seen several
disclaimers placed at the end of chart notes by other physicians. I was
wondering if anyone knows if there is a 'best' disclaimer, or if the
following is adequate.
" Note: this chart I was prepared using voice-recognition software and may
contain unintended word substitution errors."
I appreciate any replies
What appears below are two responses from a legal standpoint. I think it's
something that needs to be given due consideration
Author: Richards
Date: 08-30-04 22:41
Gentleman -- I AM a lawyer, and, although I no longer do injury work, I once
did, and am even more adamant than TechMD or Larry K. against the use of
so-called "disclaimers" -- for much of the same reasons they give.
A doctor is held to a high punctilio of precision, especially when a
typographical error compromises the quality of medical treatment received by
the patient. Putting such a disclaimer provides NO SAFETY. It merely
indicates you are 1) unwilling to proofread your work, 2) that you think a
disclaimer excuses your largess, and 3) are indifferent to the quality of
care your patient receives. This is an unequivocal indication you will
tolerate errors, and think explaining how they happen makes it OK.
Of course, this only matters if the patient is injured or patient care is
compromised by the transcription error. If there is no harm, there is no
foul...
My favorite medical speak-a-graphical error goes as follows (say it out
loud, and you'll see how easy this mistake can occur):
Podiatrist says = patient presents an acute Tedis Pedis...
DNS Types = patient presents a cute tiny penis...
So, do you think that your patient will think it is okay that your computer
made a mistake? Do you think your "disclaimer" will assuage his
embarrassment to any substantial degree?
You are responsible for the consequences of your errors whenever they
compromise patient care or lead to patient injury, regarless of whether or
not your transcription system (human or otherwise) is blame by
failingcorrectly transcribe what you dictated. The jury won't care whether
YOU made the mistake, yourself; your transcriptionist made the mistake; or
your dumb old computer made the mistake -- anyway you slice it, YOU will be
held responsible (i.e., liable) for the adverse consequences of any mistake
that yields untoward consequences.
Therefore, I wish to reinforce everything Larry and TechMD said, and the
very tone in which they said it.
So... having said that... please disregard any speak-o-graphical errors you
might find in this reply, because I am using experimental voice recognition
software ....
Happy trails to you all!
NB -- [Construe all these replies as a respectful and serious response to a
very important question. This could be a matter of life and death, and such
issues are what we call in my business, a potential "career-stopper." The
fact we weigh in so strongly merely reflects how important the underlying
question really is.]
Best Regards /// Richards ///
===================================
Author: techemd
Date: 08-31-04 09:35
Steve,
I respect your position and have heard it a number of times. The "speed with
which you lept to the opposite conclusion--broad brush in hand--" came after
working as a physician and in medical malpractice defense fro the past 18
years.
I called some attorney contacts I have on BOTH sides of the courtroom (just
to get THEIR take on the situation). The defense attoneys I contacted DON'T
want the disclaimer anywhere on the note. The plantiff attorneys I contacted
LOVED the idea and then proceeded to tell me how they would "rip the author
of those notes to shreds" EVEN IF NO ERRORS WERE FOUND IN THE NOTE! They had
some rather interesting approaches on how to discredit the author simply due
to the presence of a disclaimer on a medical note.
The attorney's I contacted couldn't agree with Richards more....Thanks!
In terms of the "broad brush"....well, I was only speaking about the
original question which was a disclaimer on a note written on a medical
record...a very specific place.
I have to add my personal favorite:
"The patient presented with a complaint of trouble breeding" (actually what
was meant was "...trouble breathing." This was NOT a mistake of voice
recognition but rather an actually typed error by a transcriptionist and if
you notice breeding is spelled correctly as well...not all the mistakes
transcriptionist make are spelling typos. I've got hundreds of them...all
spelled correctly.
One last thought....as Richards also eluded to....please accept my comments
as "a respectful and serious response". I do not wish to offend anyone or
anyones opinion but rather to help Ken from making what at least every
attorney I spoke to from making a mistake when it comes to documenting in a
medical chart.
Scott
(Disclaimer: I was tired when I typed this, the lighting wasn't good, I was
interupted constantly and I didn't proofread anything so their could be some
mistakes I didn't intend to make. I'll decide later what I meant to say if I
get in trouble.) --please take that as a joke.
If you wish to read the remaining messages on this subject, you can click on
this link:
http://s103536049.onlinehome.us/knowbrainer.com/forum/read.php?f=2&i=10732&t=10732#reply_10732