I'd like to thank Brent for sending this in. It's from a cardiologist's dictation done with Dragon, that was mailed without being proofread.
While I can understand what the doctor is trying to say, this just sounds bad, and makes him look sloppy. And the little "This dictation was done with voice recognition software and may contain errors and omissions" disclaimer (that everyone puts at the bottom these days) is just a fancy way of saying you're too damn lazy to proofread.
"Concerning symptoms are note above and the patient, who by history sounds like she has had brief episodes of PSVT. All his life. I would like to obtain an echocardiogram and if this is unremarkable. A stress echo to start her duration of the above. If these are unremarkable. We will obtain an event monitor.
He is instructed that he is not to drive a lesser correctable etiology of these spells can be found or if he does not have them for 6 months. As also instructed not to be in a situation where she has a spell. He didn't injure himself, such as being a ladder."
As a trained medical transcriptionist, this is infuriating. Clearly patient care and clarity of medical records are falling by the wayside in favor of money-saving techniques. If we can just put "report was dictated by voice recognition software" at the bottom of everything and just roll with how terrible that is... what does that say about the profession? Perhaps we should just put "report was recorded by a human being who is too lazy to proofread and/or too cheap to pay someone with the skill level to take care of it for him."
ReplyDeleteA malpractice case or two would go a long way toward reintroducing clarity.
ReplyDeleteI can follow most of that (and insert punctuation where needed) but there are a couple of spots of complete confusion. Also, the patient becomes transgender in the space of two sentences.
I can only imagine what the patient gets charged for this sloppiness.
ReplyDeleteI'm a MT, too. I see this as job security, and it makes me laugh and laugh....
ReplyDeleteWe use a dragon engine almost exclusively in the office, and it does a damn good job-IF you dictate correctly.
ReplyDeleteAnd proofreading is a necessity. Preferably while you dictate, so you can learn from your (its) mistakes.
What's the big deal? This makes complete sense to me.
ReplyDeleteThat's hysterical. Unfortunately the hospitals I rotate at use people to do the dictation so there are never any funny translations!
ReplyDeleteTrain the Dragon to the user and it works like a servant.
ReplyDeleteOh, so when the doctors order the umpteenth useless breathing treatment on a patient - it can be blamed on the mis-interpetation of the "voice recognition" software.
ReplyDeleteLike someone above said - 1 or 2 good malpratice cases will go along way to fixing this.
or maybe a couple dimes dropped on JACHO/The Joint Commission in favor of Patient Risk
Yet another reason why doctors (and nurses) should learn how to type.
ReplyDeleteBTW all the physicians (and nurses) at the Hotel have to type their own notes, which leads to use of predefined templates, which makes some of them lazy.
I always hope they use a department template, instead of making up their own. They should also have a narrative at the top, and template at the bottom, so it does make the notes look different on each visit.
This removes the temptation to cut and paste which is a big, big no-no.
Another MT weighing in here ... I also look at this as job security, because if medical records routinely contain errors and omissions, what the hell good are they?
ReplyDeleteEngrish
ReplyDeleteI've worked at home as a transcriptionist since 1995. Some doctors care only about the $, errors or not. Scary. One client left, may retire soon, and then I may look for another career!
ReplyDeleteSounds like someone had about 30mg of Ambien on board... doesn't even remember what he did. LOL
ReplyDeleteThis dictation example reminds me of the typing tests my middle-schooler has to do -incoherent.
laziness, pure laziness on the Dr.'s part.
Here at Horse HQ we, of course, find this snippet unsurprising--mild, even, compared to our usual stock in trade.
ReplyDelete--The "disclaimer," though: That's a new one. It tells us two things: 1) VR software vendors' BS notwithstanding, users are forced to realize that, when not proofread or edited, these reports are going to land on patient charts containing mistakes that raise the specter of liability; and, 2) They are actually willing to publicly declare that this does not matter.
Holy balls, that is scary.
I've heard of a human doing "first try missed her" transcribing notes for an obstetrician.
ReplyDeleteHmmm - got similar in the UK when transcription was out-sourced to India.
ReplyDeleteThis kind of laziness is dangerous. It is not that hard to read over it real quick to make sure it's clear. I can get the gist of this, but a lot of people will not be able to figure it out and thus not follow instructions. I don't think the disclaimer would protect them in a lawsuit.
ReplyDeleteThe company I worked for switched to Dragon a few years ago, it was a miserable transition time. I spent a month seriously wanting to quit my job and I loved my job. But even when the software was brandnew and it barely recognized anything I said, I never sent anything out remotely as incoherant as that mess. I can't imagine someone who finds that to be an acceptable medical record is particularly conscientious in other areas of their professional life.
ReplyDeleteSadly this is becoming more prevalent all the time in our medical records. The reality is that speech recognition technology still needs an editor, but that's not what we see happening in health care. Now the push to use natural language processing to assign data tags to the SRT document so it can meet meaningful use and go directly into the EHR means we are going to end up with one huge mess in healthcare documentation. At some point, all of that will have to be fixed. I have never understood the need to not do it right in the first place.
ReplyDeleteApparently he snot a wear of the impotence of proofreading.
ReplyDelete"He should have followed these two Pisces of advice: One: There is no prostitute for careful editing. And three: When it comes to proofreading, the red penis your friend." From Taylor Mali's poem called, The Impotence of Proofreading.
2012 is the 'Year of the Dragon';
ReplyDeletewe may need to get used to this?
Also my 'animal' sign, as it happens.
Win some, lose some, I guess....
WV: mushgo
So my 10 cents is used up!
Happy New Year, Dudies!
I used to think of this as job security, too - until I got laid off last week. Unfortunately, our medical imaging VR dictation system (Dragon, naturally) with the built-in medical vocabulary still, after five years, routinely renders "first trimester ultrasound" as "Mr. Ultrasound". I have a huge blooper file of these. They still need editors, obviously!
ReplyDelete-- littlefoot