Medical Voice Dictation Compliance | What to Watch Out For
Speech dictation and electronic medical record systems offer to make the office more efficient and data entry more accurate.
However, there are potential legal repercussions when these systems are not implemented responsibility.
We’ll lay out the two big ones below.
‘Dictated but not read’
When you speak into your Nuance dictaphone to enter notes into a patient’s record, at some point you need to read over what has been recorded to ensure accuracy.
“A significant risk associated with the practice of marking reports or entries ‘dictated but not read’ is the possibility that incorrect information becomes part of the patient’s medical record indefinitely,” warns the Canadian Medical Protective Association.
“The incorrect information could be relied upon by other physicians when making treatment decisions, increasing the risk of a patient safety incident. This could lead to a legal action involving the dictating physician and possibly the subsequent treating physician.”
Different jurisdictions have their own policies regarding how long a physician can wait between the dictating of notes and a review of them to ensure accuracy. However, it needs to be done because years later before a disciplinary hearing or a courtroom, a doctor will rely upon those notes to fill in the holes where memory fails. An opposing attorney would have a field day with notes that were ‘dictated but not read’.
Watch out for imitators
Generic speech recognition softwares don’t cut the mustard legally from both a patient privacy perspective and for accuracy in recording medical records.
Dragon Medical Practice Edition II was designed to meet or exceed the requirements of the HIPAA Act in the United States and The Personal Information Protection and Electronic Documents Act in Canada.
The law in Canada requires that whenever personal health information transits a third party, it must be heavily encrypted. As soon as you speak into your Dragon Medical Power Mic II, your data is securely encrypted. Generic voice dictation softwares that weren’t created for the medical profession, don’t meet this test.
The other shortcoming of the generic dictation softwares is that they don’t have the specialized vocabulary of Dragon Medical Practice Edition II. The danger here is that when entering medically technical data into your records with a generic software, you have a large room for it to misinterpret the data. That opens you to a world of legal liability.