A while back I wrote a blog about a resident’s operative dictation that was incoherent and the pitfalls of dictating. Here is another example.
The switch to electronic medical records has brought some unintended consequences. We now have rapid turnaround of dictations at my hospital. They appear in the electronic record within a couple of hours and require verification by electronic signature. As is true of many documents that appear on computers and the Internet, they sometimes are not read carefully.
It was electronically signed by the physician who dictated it. I’m guessing that he did not proofread it. At least I hope not.
The name was changed to protect the innocent.
Dr. Balotelli found on endoscopy a stomach full liquid with esophagitis. There was a 3 orifices in the distal esophagus. There is a hiatal hernia sac, actually 2 of them; 1 led to the antrum. Pylorus and duodenum of the hernia sacs are full with dark liquid which were suctioned. The third compartment led to the small bowel. It did not contain any contents. The hernia sacs were friable and ulcerated. The mucosa in the antrum and pylorus were widely open. The duodenum appeared normal. Since then, the patient is no longer nauseated or vomiting. His NG output is minimal.
As far as I know, I am the only person who has actually read this note. The entry was made a while ago and has not been corrected.
I used to use Dragon dictation. You must take great care when proofreading because you tend to read what you meant to say, rather than what Dragon thought it heard. I once dictated a letter of recommendation for a student. Instead of Dragon typing "she is confident and poised," it came out "she is confident and moist."
Does anyone really read electronic progress notes?
Do you know of any examples of dictations gone astray like this? If so, please describe.
A slightly different version of this post appeared on Sermo yesterday. Most of the comments suggested that the EMR would be the downfall of society as we know it.