The latest comment that drew my interest is Lea Sim’s response to one of my comments, where she says:
…unless we can make a solid argument to someone like CMS or HHS or the Joint Commission that there is at least SOME risk to the patient in having unqualified hands in a health record, considering how inconsistently physicians actually read the records they put their signatures to.
I have disagreed with this position in the past and I’m going to keep disagreeing with it.
I want to know if there are any other highly educated, highly trained professionals preparing medical-legal documents who wouldn’t be expected to ensure that those documents are accurate before they sign them. Oh heck – I don’t know of many professionals, highly trained or otherwise, who don’t understand it’s their responsibility to ensure the accuracy of the documents they sign.
I was a secretary for years and not only are non-medical professionals as a whole more conscientious and courteous about their dictation, they all also understood that they needed to actually read the transcribed document before they signed it. After all, that’s their name on it, not the transcriptionist’s. Whoever is going to receive the document doesn’t know – and frankly doesn’t care – who typed it. If there’s a problem with it, they call the person whose signature is at the bottom, they don’t start hunting down the person who typed it.
I’ve had insurance adjusters read a transcribed letter telling a claimant that their case has been settled more carefully than some doctors read an operative report before they sign it. That’s not a reflection of how much either professional trusts the person who transcribed their dictation, either.
Now, I understand that doctors are busy. But really – what special power relieves them of the responsibility of making sure that the medical records they create and have responsibility for and to which they affix their signature are an accurate representation?
Let me quote myself, from a prior post Whose medical records are they anyway?
Let me review, in case anyone missed my comments a couple years ago in Advance for HIM. The average medical transcriptionist has a high school education. The average physician has a high school education, plus 8 years of higher education. The average medical transcriptionist is trained on the job. The average physician spends three to six years in internship and residency training programs. The average medical transcriptionist makes less than $30,000/year. The average family physician makes over $130,000 a year, and that’s the lowest-paid group; specialists can make up to $800,000 a year. Physicians are one of the highest-paid occupations in the U.S. The physician is trained, licensed and paid to make medical decisions; the medical transcriptionist is not. The records belong to the physician, not to the medical transcriptionist. When the physician signs the document – with a pen or electronically – he or she is verifying that it is a medical-legal document that is true and accurate to the best of his/her knowledge.
Which one of these people do YOU think should be responsible for making sure the documentation is correct?
As long as AHDI keeps beating this drum, I’m going to keep repeating myself. This is a dangerous, slippery slope. Making transcriptionists responsible for the accuracy and completeness of the medical record does not make medical transcription more valuable in the healthcare community.