Inaccurate dictation gives providers headaches
Education helps improve patient documentation
Maybe the physician knew what he meant when he dictated this sentence: "Patient is a 26-year-old mother of seven who apparently was in the operating room for some reason, but fell asleep when it was discovered that she was pregnant at another hospital."
This may be amusing to some, but would you laugh it if were in a family member’s chart? Would you be amused if the confusion delayed your reimbursement?
Unfortunately, the problem of incomplete or inaccurate dictation is not uncommon, says George Heymont, managing partner of Alert & Oriented Medical Transcription Services in San Francisco. Some physicians often don’t make sense in their dictation. "They are either distracted or tired or not paying attention," he adds.
Some common transcription problems include:
wrong lab figures;
medication names that don’t exist;
incomplete contact information, such as a letter addressed to Dr. Smith in Pennsylvania;
muffled dictation, often the result of a physician eating while dictating or trying to dictate on a cell phone;
random substitution of the words left and right to indicate the location of a procedure.
For example, a physician operates on a patient’s left leg. "All the way through the dictation the physician says the left leg. Suddenly he starts saying he is operating on the right leg," he says. "Sometimes the physician even changes the location of the operation in every sentence."
Other common dictation problems include:
Switching gender-specific pronouns.This can be a problem for doctors who are using English as a second or third language. A Chinese physician, for example, may be thinking in Chinese while trying to speak in English. "Because he is thinking in Chinese, he is not using gender-specific pronouns," notes Heymont. As a result, the notes may state that a 58-year-old man is having a hysterectomy.
Omitting gender-specific pronouns on patients whose names do not indicate a gender.Although dictation errors mostly involve physicians not including the information needed to support a particular diagnosis and level of reimbursement, the problem can involve the inclusion of too much material in the record, as well.
"Some doctors document too much," says Catherine Baxter, vice president for encryption re-engineering services for Diskriter in Pittsburgh. "They dictate far more than is required. They bury the important information."
Aiding and abetting
Perhaps part of the blame can be placed on the system. Many physicians used to rely on one or two transcriptionists who knew the patients and the physicians’ idiosyncrasies. But times have changed.
"Many physicians have sloppy [documentation] habits, and they have always depended on everyone to pick up after them," Heymont says. The problem is exacerbated when physicians sign off on reports without reading them.
The facilities with the highest occurrence of incomplete or inaccurate dictation are those that are afraid to confront the guilty physicians. "No one wants to tell the doctor he made a mistake," he says. "There is a lot of denial."
Third-party companies that handle outsourced transcription also may be afraid to ruffle the feathers of a client and possibly lose the account. But if the Health Care Financing Administration (HCFA) in Baltimore kicks back the record for incomplete documentation, the responsibility begins and ends with the health care facility — not the physician or third-party company.
"When you outsource the function, you can outsource the task but you cannot outsource the responsibility or the quality of that task," Baxter says. "Ultimately, the facility is still responsible for the quality of that work. It’s often the case that not all the work comes back in excellent quality."
Some third-party transcriptionists, however, don’t hesitate to send records back to physicians with blanks in areas where they couldn’t understand what the doctor was trying to say.
"Then we have to take that report back to the doctor and ask for his or her help to fill in the blanks. If physicians have to do that often, some of them will often slow down and take the time to try to get it right the first time," says Mary Brandt, MBA, RRA, CHE. Brandt is vice president for professional services in the health information solutions division for QuadraMed Corp., a health care information technology company based in Richmond, CA.
She says she often finds when a facility chooses to outsource, it outsources everything. "It does not maintain a qualified medical transcriptionist to do [quality assurance]. It may have a clerk or someone like that to look over the reports."
That is not an acceptable alternative, she adds. "There are some valid reasons why you can’t complete a report. You should have a quality assurance person in place to review the records."
Looking for solutions
Some industry associations say they are hoping formalizing standards for transcription will help increase record accuracy. Heymont doesn’t agree. "You are not necessarily getting [the dictation] right and you are still not solving the problem, which is teaching doctors to communicate."
Heymont, who recommends the book Dictation Therapy for Doctors, suggests requiring physicians to take a certain amount of continuing medical education on how to properly create documentation. He also suggests doctors keep their certificate of completion on file with the medical records director of any hospital where they have admission privileges.
The cost of inaccurate or incomplete records is increasing every day. If hospitals don’t have the right documentation and the right elements in that documentation before the codes are applied to patient visits, two things could happen, Baxter says:
Hospitals will experience delays in reimbursement. HCFA will challenge the level of coding facilities assign."They’ll either have to respond with more documentation, which is going back to the doctor for additional clarification, again delaying the reimbursement," she explains, "or [HCFA will tell them], This is not clear, and we’re not going to pay that much.’ The primary reason for this is a failure to document what’s necessary and in a proper format that can be readily understood and found within the documentation."
Both Baxter and Brandt emphasize physician education as one part of the solution. Diskriter’s director of education and training, for example, will be working with corporate compliance officers to develop a program that will help instruct the physician on what to document and what to delete.
Facilities also can educate physicians about the liability that they have if their dictation is inaccurate or incomplete, Brandt says. "Hospitals that are having a significant problem with that might consider bringing in an attorney or an expert to do a seminar for the medical staff about liability issues involved in documentation. Physicians do care about liability, and they do care about patient care."
Giving physicians guidelines for dictation can be helpful, too, she adds. For example, some hospitals give physicians handouts for what should be included in a history and physical, a discharge summary, a consult, and an operative report. "Some hospitals even make small laminated wallet-sized cards that physicians can carry with them and refer to."
Physicians also are taking more notice when they are penalized for records that have faulty documentation. "The only way to wake them up is to hit them in the pocketbook," Heymont says.
Peer pressure works, too, Brandt says. Records from physicians who routinely document next to nothing or make statements that are possibly inaccurate should be reviewed and taken to a committee of peers. "For example, if you have someone in surgery who never dictates what he or she should in an operative report, then I would suggest reviewing those records and taking them to the surgery service and asking if this is acceptable documentation for this service. Generally the service chief will say no.
"Then the service chief can take action with that particular physician. That is usually more effective since it’s physician to physician," she says.
(Editor’s note: For more information, contact: Alert & Oriented Medical Transcription Services, San Francisco by e-mail: www.wwma.com/alert.html.)
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