At 2Ascribe Medical Transcription, we pride ourselves on accurately transcribing your dictation. All our work is proofread and double checked by our professional editors to ensure there are few to no inaccuracies, and that the information, documentation, course of action and next steps are meticulously detailed and precise. The last step of the review process is you, the author of the report. After we provide the transcribed report to the dictating physician or healthcare professional, there are occasions when the transcribed report needs to be forwarded immediately without review. This results in a “dictated but not read” signature appearing on the clinical record. Though this practice can expedite and facilitate ongoing patient care, it comes with risks. The Canadian Medical Protective Association (CMPA) outlines these risks in their article, “‘Dictated but not read’: Unreviewed clinical record entries may pose risks.” These are some of the main risks highlighted in the article.
Legislative and Regulatory Risks
The CMPA outlines that legislative and regulatory policies may require physicians to review and sign dictated reports within a specified period of time. Failure to comply with applicable regulations could lead to disciplinary action from their hospital, health authority, or College.
A significant risk with reports marked “dictated but not read” is the possibility of incorrect information becoming a permanent part of a patient’s medical record. As Stanley Shere outlines in the British Medical Journal, unreviewed transcription errors can lead to diagnostic and treatment errors on a patient’s record and create problems during ongoing patient care. The CMPA notes that these unreviewed errors could “launch a legal action claiming that the physician who made the dictation was negligent.” Furthermore, they explain that it is unlikely that “administrative convenience or efficiency will be accepted as a legitimate rationale for failing to ensure that a transcribed report is reviewed for accuracy and finalized within a reasonable time.” It is in a physician’s best legal interest to review the accuracy of transcribed reports promptly.
Medical records in legal proceedings
Finally, the CMPA focuses on medical records used in court proceedings. These proceedings may take place “many years after the advice or treatment was provided and a physician may not have an independent recollection of the patient.” In this case, “accurate medical records are often a physician’s best defence. Conversely, inaccurate or incomplete records can be highly detrimental to a physician’s defence.” This again highlights that it is in a physician’s best legal interest to review the accuracy of transcribed reports promptly.
The best practice to avoid the above risks is to avoid including unreviewed dictated reports or entries in medical records, according to the CMPA. If you have a “dictated but not read” report, ensure that you review it within the required timeframe outlined by your regulatory bodies. At 2Ascribe we strive for 100% accuracy with quick turnaround times on dictations allowing for quicker physician review. We also assign specific clients to specific transcriptionists and quality control people, to further help with improving the accuracy of your transcribed documents.
Here is a link to the CMPA article for more detailed information: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2016/dictated-but-not-read-unreviewed-clinical-record-entries-may-pose-risks
2Ascribe Inc. is a medical transcription services agency located in Toronto, Ontario Canada, providing medical transcription services to physicians, clinics and other healthcare providers across Canada. Having recently introduced WEBscribe, a client interface portal for document management, 2Ascribe continues to implement and develop technology to assist and improve the transcription process for physicians and other healthcare providers. As a service to our clients and the healthcare industry, 2Ascribe offers articles of interest to physicians and other healthcare professionals, medical transcriptionists and office staff, as well as of general interest.