So I'm reading a note yesterday on a nice little old lady:
"When I went back into the room the patient was clearly intoxicated and verbally abusive. Her husband took off his belt and tried to hit me with it. Security was called and the husband was physically restrained, though he bit a guard in the process. The patient was put in 4-point leathers and given Haldol when she attempted to punch a nurse. Sorry, please ignore that, it's the wrong chart. Please rewrite it as: her head CT was normal, and I think she has benign positional vertigo. She and her husband were satisfied with this, and I gave her a prescription for Antivert. She'll follow-up with Dr. Grumpy next week in his office."
32 comments:
you can't undo anything?!? wow!!! who designed (and approved) that system????
No kidding, that must be annoying as hell.
@Julie I guess somebody who never tested this kind of Software before, and Someone who is so far away from the ER that he will never be left holding the bag of this system.
Wow. No way I'd use something like that...gotta be able to edit! I once used a certain chat program until I realized that the person I was chatting with could see everything I was typing in real time, as I was typing, so there was no going back and changing my mind about what to say. Ack! No way. If I want that type of interaction I'll talk! :o
These are all descending from the quality/ISO paradigms the industries use: never write in anything else than non-eraseable pen, never scratch any writing to make it unreadable, etc... it's a way to ensure that no critical information is deleted for any reason...
See how well it applies to EVERY situation? [/sacrasm]
ER, where the action is. Drunks, aggressives, drug out zombies and the people trying to help them.
Hey, I think I just thought of a new TV show.
What ??? Oh, nevermind.
BIG oops .
seems like something malpractice attorneys pushed for. if we never made mistakes, we'd be considered robots.
Wow! My attorney acquaintances (not friends) would LOVE this system!. Think of the lawsuits, er profits, to be made with this Dragon Dictate!
As a previous poster said, it *does* make sure nothing is lost and you mischievous doctors don't mess with the records.
But, this is not apparently Dr. Grumpy's prospective patient. At least I hope not.
But, this is a major HIPAA violation. Hear the herd of ambulance chasers coming? Hope the hospital has cleaned up its act or got a better class of programmer in.
As an aside, I had a follow-up appointment with a surgeon about a procedure. I had gone back to work a LOT sooner than he thought wise, but I had to as I needed to give a deposition in a suit against my company. No, it could not be put off. I explained this to him, and he wanted to know the name of the person who had filed the suit. He was a little put out when I pulled “ethics” (and not telling details) on HIM.
Hmmmmmmmm ...
Does this become part of the patients permanent record? If they were to request everything from the hospital stay for their own personal records, would the patient/patient's family member be able to see this? Sure hope they have a sense of humor.
Back in the day before all this HIPAA crap (when the full charts used to be outside the patients room on "the rack"), I would often pick my grandfather's up, bring it into his room and read through the notes and reports from the previous day/evening. The first few sentences, on the very first page read (this was typed from dictation; I would imagine):
The 18 y/o old female patient was admitted on XX/XX/XX for CHF. She has prostate cancer, kidney disease..............
I pointed it out to the nurse and she said, "It's no big deal and won't change the treatment plan?"
So, I took out a pen, changed the 18 to 81, crossed out the "FE" and changed all the she's to he's on that first page.
Wow, that sounds like a ridiculous software program! With as many people who would come into the dictation room and interrupt me, I can only imagine what a mess that would be to type, and then to understand. So glad that I retired early.
I'd think not being able to undo anything could lead to a HIPAA violation.
Our hospital also uses a Dragon-like software, and it's nice because it's very fast. Before you electronically sign your note, you can "modify" it. Once you sign it, however, it's too late. A lot of folks just sign the note without carefully reading it for typos. Makes for some humorous reading later on.
That freaking awesome. Imagine how psyched the patient (and a lawyer) would be if they got to read their own medical records.
I gotta ask -- how often do you almost get assaulted by your patients?
aren't you glad he sent you the SECOND lady and not the first one??!!
And this is how Mike Myers came up with his "not!" catchphrase.
As a medical transcriptionist this really hits a sore spot with me. My job is not only to type the dictation, but also to edit obvious errors (she for he, etc.) and FLAG anything that just does not make sense so that the dictating provider can fix the report. Between the voice recognition software that many medical transcription companies have gone with and Dragon the only people who are going to win in this situation are the malpractice attorneys and the Indian companies that own the software (yep...Dragon is owned by an Indian company). It is time for the physicians to put their feet down with the hospital administration idiots making these decisions to save a buck. They certainly are not going to be saving any lives with the garbage that comes out. C'mon docs! Support your U.S. based MTs and refuse to use Dragon or have your reports run through voice wreck, insist they be typed by a medical language specialist! Okay...sorry Dr. G...but this makes me the GRUMPY MT!
The opinion stated here is my own and every other U.S. based medical transcriptionist! Vent over.
Ummm... just to set the record straight on Dragon... they're not owned by an Indian company; the Dragon brand is owned by Nuance, based out of MA, publicly traded (Nuance swallowed up the company that had swallowed up little Dragon many years ago). End of niggle. Nuance does indeed vigorously market their VR products to MTSOs (translation: Big ol' transcription sweatshops) that outsource big-time; thus they, too, contribute to the demise of medical transcription--both the job and the concept. Grumpy MT is right: Going straight from dictation to the chart with no human oversight is bad, bad, bad. Read Dr G's post again, and if you still don't believe it, see my blog. (Thanks for letting me blog-whore, Dr G!)
IT guy here: I don't have a problem with making it impossible to erase things after you have had a chance to review them in a situation like this--it ensures the integrity of the chart which could be valuable if there's a lawsuit.
However, it should be possible to flag an entry as deleted and omit it from normal display or at least do something like drawing it with a strikeout so it's absolutely obvious it was meant to be deleted.
While your chart would still have the words from the drunk you wouldn't have to read through them.
Same thing happened in my office when dictating a patient's Holter Monitor report using Dragon : Instead of "the patient's diary was returned blank" it came out as "The patient's diarrhea was returned black"!!!!!
Ah, you can take the girl out of the ENG lab, but...I was laughing at this until I got the end, and then I just had to flail about the antivert for BPPV. Put the drugs away and just FIX IT. (Tell me you're going to do one of the repositioning maneuvers when she gets to you?)
@Grumpy MT
Dragon is made by Nuance Communications. Their headquarters is in Burlington, Massachusetts. Not India.
"Oh...oh, yeah....yeah, keep doing that...oooh, that feels good....oh...oh....mmmmmmmmmmmm.....AAAAAHHHHH........Sorry, please ignore that. Patient came in complaining of cluster headaches..."
In nursing we have a saying that the relevance of a policy is inversely proportional to the distance the policy writer is from the bedside. Sadly, most administrators are as far from the bedside as they can get. Apparently so are the IT staff.
Well... I can see how this would suck... I can also see how it's better than our transcriptionists simply leaving out groups of words or entire sentences because they feel like it. And when you catch on to it and kindly enquire where the missing words are, they get all pissy about how dare you correct them and really, there was no need to put -that- into discharge papers.
@anony My mistake about Dragon being Indian owned. M-Modal (speech wreck) was recently purchased by Medquist, which is Indian owned.
@Snarky Scalpel: It is unfortunate that there are those lazy MTs out there who make all of us look bad and lead to providers wanting to use Dragon. The professional MTs would never dream of leaving out dictation or worse, challenging the provider on what they do or do not put into their reports. Unfortunately most MTSOs (lol at Big ol' transcription sweatshops Horse) are urging quantity over quality these days. While charging their clients for the "personal touch" of an MT they are actually running the dictations through voice wreck, paying the MTs to "edit" this and urging them to do it as quickly as possible. The only way to have a reliably accurate medical record is to have a professional MT type it, proof it, and get paid a reasonable wage for doing so.
I personally find it hard to believe this is a true Dragon product - I have been using Dragon for a number of years and NEVER have I not been able to edit my dictation. Secondly I find editing speech recognition a refreshing change from pounding on the keyboard after 40 years - by that's just my opinion.
Damn, all those charts start to look alike, don't they?
Is this a story about Dragon (which after all is just a keyboard substitute) or a story about a brain-dead charting system? Was the charting system designed by Dragon?
Don't know. The dictation system is dragon, but the charting program itself is likely a completely separate company.
I did not end up going into nursing, but while in the course I was taught it is illegal (in Canada) to delete anything from a medical record. You cross it out (and initial it) but it must still be readable. I can see why it would be necessary, to keep people from altering records to cover their asses, or whatever.
so good. this happened once in our icu system... except they wrote a death note. my guilt-wracked intern hunted down the family to express his sorrow... and they were so confused. we went back to see the note amended "entered on the wrong patient. mrs smith is, in fact, still alive."
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