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Be wary if your doctor uses phone dictation to take notes

Medical errors can be caused by many factors. Previously cited culprits include unforeseen interactions between medications, increased stress on doctors, and perhaps even just old fashioned poor communication. A new addition to the list of medical malpractice contributors might surprise you: phone dictation.

According to a recent study published in the Journal of the American Medical Informatics Association, a patient’s care may be affected by the way his or her health records are electronically documented. The study found that the quality of care appeared “significantly worse” for physicians who dictated patient information over the phone. In contrast, those that typed their notes directly into the patient’s electronic health record (EHR), either in free text or by using templates, scored better in several quality measures.

The authors of the study believe that inputting information directly into a patient’s EHR, instead of using dictation, may require physicians to pay greater attention to coded fields and clinical decision support, and thus deliver higher quality care. Physicians that use dictation, which is faster, may not be paying as close attention to information and alerts in the EHR that may be crucial to patient health.

One of the most important steps you can take in ensuring you receive quality health care is to be as accurate as possible in filling out the paperwork given to you upon entering a physician’s office. However, if you have been injured by a doctor’s care, an attorney can help you investigate whether the cause was a breach in the standard of care applicable to medical professionals. If that was the case, an attorney can help you gather the evidence and medical experts that will prove that your doctor committed malpractice.

Source: FierceEMR, “Care quality ‘significantly worse’ when docs dictate notes by phone,” Marla Durben Hirsch, May 23, 2012