February 2014

When Dictators Fail
By Juliann Schaeffer
For The Record
Vol. 26 No. 2 P. 14

Experts offer nine suggestions on how to combat dictation errors.

Whether caused by human error, such as a dictator inputting an incorrect patient medical record number or date of service, or poor audio quality from background noise or equipment malfunction, finding errors in clinician dictation is not uncommon. Yet because physicians are human, no matter how many medical miracles they perform each day, eradicating these miscues may be a fool’s game.

“I do not believe it is realistic to expect that dictation errors will ever be eliminated completely,” says Cynthia Vogt, vice president of A+ Network Transcription Services. “There are too many variables involved, and while human error certainly remains a component, speech recognition cannot guarantee 100% accuracy either.”

However, that doesn’t mean medical language specialists (MLSs), also known as health care documentation specialists, can rest easy because even though they may not be responsible for creating all of these errors, it’s on them to catch them. Should they fail, patient care can be affected, sometimes drastically. “The potential consequences of dictation errors can range from minimal to life threatening,” Vogt explains. “For example, Roxanol is a highly concentrated solution of morphine sulfate for oral administration. A dosage error or confusion between milligrams [mg] of morphine and milliliters of solution may cause significant overdosage. If a doctor is heard to say that a patient is ordered 100 mg of Roxanol every four hours instead of 10 mg every four hours, the consequences could be lethal.”

Equally, if a physician incorrectly dictates right for left as in “right breast positive for carcinoma,” it can lead to devastating consequences.

“[Clinical dictation] is about communicating the patient’s story for the next provider that’s going to be a part of the patient care experience,” says Bruce A. MacLeod, MD, FACEP, president of the Pennsylvania Medical Society. “And if that’s incorrect, then it could lead to additional testing or even insufficient testing, so it leads to patient care errors of commission and omission.”

Decisions such as what testing patients should undergo and when are made in real time while the patient is under direct care, according to Karen L. Fox-Acosta, CMT, AHDI-F, immediate past president of the Association for Healthcare Documentation Integrity (AHDI) and quality assurance (QA) manager for Shumaker Transcription Service. “The patient’s medical history directly impacts how a particular treatment or disease process might be addressed,” she says. “The patient’s health record is a legal document that represents plan of care and actual care, and documents outcomes. Errors in the document, at the very least, can be confusing for the patient, family, care coordinators, clinicians and, at the very worst, can cause the death of the patient.”

Factor in the breakneck speed at which technology is changing, and Fox-Acosta says a single dictation error can create ripple effects throughout an organization. “As technology evolves and as health systems become more interoperable, a single error is exponentially replicated throughout multiple venues along the workflow path inside and outside of the institution to include consulting patient care, billing, and data aggregation as we start to utilize the power of the electronic health record,” she says.

Though dictation errors are an unfortunate reality, Fox-Acosta says there are ways for health care documentation specialists to at least reduce the factors that enhance the potential for errors and consistently strive for better documentation practices.

From cleaning out listening ears to cracking open a medical terminology book (and consulting it often), For The Record has corralled nine tips for ensuring the most complete and accurate documentation despite less-than-perfect dictation files.

1. Check once, then check again. According to Brandy Gorda, transcription manager for Emdat, proofreading a final transcribed document prior to signing off on it can be key to catching errors. “Proofreading the work prior to routing to the physician is key to proactively identify errors,” she says. “If it doesn’t sound right when it’s read back, it probably isn’t correct.” Listening to the report while proofreading can help identify even more errors, she adds.

In addition to proofreading an entire document, Randolph says certain information, such as patient names, medical record numbers, and dates, deserves a double check. “Always compare the MRN [medical record number] and the patient name to be sure they match,” she says.

Proofreading also should catch any left-right, he-she inconsistencies. “Watch for inconsistencies [when proofreading], and stop and make sure everything matches throughout,” says Janice Jones, senior implementation consultant for the eHealth Documentation Solutions business of 3M Health Information Systems. “For example, if the physician dictates about a 16-year-old male with prostate issues, you know something isn’t quite right.”

2. Know your stuff, especially anatomy and physiology. According to Vogt, a health care documentation specialist with an in-depth background of medical metrics is second to none. “For me, the best tip is to have thorough knowledge of anatomy and physiology, lab and radiology values, and surgical and medical terminology,” she says. “A knowledgeable MLS knows lab value parameters, correct dosages for medications, and what makes sense.

“If a doctor dictates that a patient has hypokalemia but his potassium level is 8.1, a good MLS knows that the two statements do not correlate,” she continues, noting that before health care documentation specialists start transcribing, they should know the meanings of prefixes and suffixes (eg, “hypo” means low) and that normal potassium values generally range between 3.7 and 5.2 mEq/L. “Hypo- vs. hyper-, left vs. right, and pre- vs. post- are just a few examples of words the MLS needs to pay particular attention to.”

Jones says health care documentation specialists should arm themselves with medical knowledge, particularly the following:

• what drugs work for what indication;

• appropriate context for common homonyms such as perineal/peroneal/peritoneal, aphagia/aphakia/aphasia, mucous/mucus, and obfuscation/obstipation;

• a thorough understanding of anatomy and physiology to know context of the body part or system described in the dictation;

• common normal lab values to recognize outliers; and

• age-relative ailments.

“Ensure adequate training and superior knowledge of medical language, diagnostics, medications, disease processes, anatomy/physiology used for various work types, authors, and medical specialties to be able to transcribe or edit content in context,” Fox-Acosta says, adding that credentialing from the AHDI quantifies this knowledge.

3. Reference other tools for help. When in doubt about whether a piece of dictation makes sense, Debra Randolph, CMT, manager of documentation integrity for Moffitt Cancer Center in Tampa, Florida, recommends consulting a reference tool. “Check a drug book to see if the dosage for a medication is actually available and to see if the dosage sounds right for this situation and patient,” she says.

No matter how seasoned or knowledgeable, no one knows it all, and questions undoubtedly will arise. For those times, Fox-Acosta suggests having excellent tools available at your fingertips. “The spectrum of tools is vast and includes, but is not limited to, research resources like BenchMark KB, word books, and reliable websites,” she says, adding that access to sample files and accurate and efficient expander software also are useful.

According to DeeAnn Logan, a vice president at M*Modal, quality reference materials can help build context. “Resources like qualified samples—sample dictations scrubbed of any protected health information from a specific dictator—can be extremely valuable for medical transcriptionists,” she says. “Since dictators tend to use the same phrases when dictating, these samples can help to clarify later dictations.”

Referencing previous documents by a dictator in question occasionally can provide enough context and clues to resolve an issue, Jones says.

4. Continue your education. Fox-Acosta recommends all health care documentation specialists commit themselves to lifelong learning to keep abreast of any changes in medical terminology or documentation. “Consider credentialing as a way to quantify your knowledge and enhance the education process,” she says.

At Moffitt Cancer Center, Randolph says continuing education has helped to remind staff of common dictation errors. “We also have in our dictation system a way to set up MT [medical transcriptionist] notes,” she says. “These are notes that have been inserted into the system to remind the transcriptionist about particular things. We have them attached to specific dictators so that when the transcriptionist goes in to transcribe the note, this little reminder pops up for her to read.”

“Continuous training and furthering their education are examples of proactive steps that MTs can take to minimize errors,” Logan says. “The ability to edit a speech recognition document requires specialized training and a different set of skills than standard transcription. Even the most veteran MTs can benefit from continuous training and education.”

5. Sharpen listening skills. All health care documentation specialists need to listen to transcribe dictation files, but just how they listen can go a long way to ensuring accuracy and document integrity. “Listening to the dictation as a whole entity rather than fragments will help ensure accuracy,” Vogt says. “For instance, a good MLS will remember that the doctor dictated in the past medical history that the patient had a left leg amputation, and when he dictates in review of systems that ‘extremities have no gait disturbances,’ the MLS will recognize the discrepancy and notify the dictator.”

“I call it content in context,” Fox-Acosta says. “You are paying particular attention to disease diagnoses, medications, anatomy/physiology, or diagnostic data that are cohesive and relevant to each other. You are looking for omissions as much as inaccurate information.

“Always listen not just to the words but be on alert for what the author meant to say,” she adds. “This goes beyond the action of simply listening and transcribing what is said. It takes dictation/transcription/editing to the next level of content in context and having your brain on high alert for discrepancies.”

Being an active listener holds an advantage over a passive approach. “We used to call this ‘in the zone,’” Fox-Acosta says. “As dictation becomes more complex and a multiplicity of factors changes the landscape of our craft, the ‘zone’ can be extremely costly in terms of missing distinct clues within the dictation to alert for errors.”

This may require fine-tuning not just listening but also concentration skills. “Something I learned long ago in this field is I had to train my brain to listen to one voice,” Fox-Acosta says. “There can be so much background noise either in the dictation or within your office environment that you have to be able to zero in on the author’s voice. As a consequence, I can no longer multitask different people talking at me at the same time. I must ask people to stop and speak one at a time. It is a concentration issue as much as it is a learned skill.”

6. Partner with physicians. Health care documentation specialists may be wary of addressing physicians with dictation issues for fear they will be viewed as insignificant or beneath them. However, MacLeod appreciates the human touch of such encounters as well as the more accurate and complete patient files they help create. “I do appreciate that a human being is listening to what I’m trying to say and is there to improve my grammar and fix my linguistic errors so that it makes a more readable chart,” he says. “I do appreciate that kind of teamwork that we have in terms of making a better document.”

MacLeod, who encourages health care documentation specialists to approach physicians about dictation problems more proactively, says it’s in everyone’s best interest—and intention—to get documentation right the first time. “Physicians want their dictation to be good the first time because it’s much more difficult to go back and correct mistakes or try to fill it in [after the fact],” he says. “That just makes double work for everyone.”

According to Jones, there are several ways health care documentation specialists can work with physicians to create better documentation on the front end. First, she suggests following up on flags/blanks to see how they were resolved and to learn from them. Another tip that may help is sharing bloopers in medical staff meetings to emphasize the importance of good habits. “Such presentations are usually well received when delivered in an entertaining way,” Jones notes.

Even more entertaining, Jones and colleague Jill Devrick, a 3M product analyst and the current AHDI president, suggest initiating some friendly competition by presenting an award for best dictator at physician staff meetings. “Periodically publish the average speech recognition scores for the entire organization and/or specific departments and then privately share individual scores with each dictator so they can see where they stand,” Devrick says.

According to Devrick, AHDI’s Dictation Best Practices Tool Kit can help train and support physicians in developing good dictation habits. “Teach documentation requirements and dictation dos and don’ts to new physicians and residents during orientation,” she says. “And provide periodic in-services and/or other communication with physicians on dictation standards and protocols.”

7. When in doubt, leave it out. When all else fails, Randolph says a blank space is better than an inaccuracy. “Our motto is ‘if in doubt, leave it out,’” she says. “It is better to leave a blank in the document than not to be 100% sure and to make a guess at what is correct.”

In such instances, Jones recommends health care documentation specialists flag the document and ask the physician or a QA reviewer for clarification.

Fox-Acosta agrees, noting, “If you are unsure, if something does not feel right, if you know there are distinct discrepancies, have someone else—perhaps with fresher ears and thought processes—listen to the audio and [view the] transcribed information. Ultimately, flagging to the author/clinician to review can be extremely important to highlight discrepancies and provide clarity.”

8. Gain experience. There may not be much rookie health care documentation specialists can do with this tip, although knowing that it gets easier with experience may provide some solace during early rough patches. “The longer you transcribe, the more familiar you are with the terminology and the more you are able to recognize correct and incorrect dictation just by seeing it typed,” Randolph says.

9. Don’t skimp on sleep. Lastly, a well-rested health care documentation specialist is prone to catching more dictation miscues and inputting less transcription errors. “Avoid fatigue,” Fox-Acosta says. “Stay rested, well hydrated, and take breaks so you’re at your best at all times when transcribing, editing, or doing QA review.”

— Juliann Schaeffer is a freelance writer and editor based in Alburtis, Pennsylvania.