Dictated, but not read

January 20, 2006

Our practice produces so many reports and progress notes, it's hard to find time to review them. So we often file the transcriptions in the patients' charts without reading them. We stamp them "Dictated, but not read." Any problem?

Q: Our practice produces so many reports and progress notes, it's hard to find time to review them. So we often file the transcriptions in the patients' charts without reading them. We stamp them "Dictated, but not read." Any problem?

A: Yes. If you don't review your transcribed notes, you'll miss typos, like a missing "not," for example, that could totally reverse what you meant to say. Also, if these records are ever called into evidence at a malpractice trial, a plaintiff's attorney might use your perfunctory stamped note to persuade the jury that you were too rushed to do the job right or that you just don't care about the accuracy of your notes.