To err is human. But errors in medical transcription can have far reaching consequences if they are critical. The integrity of medical documents and patient safety could be seriously compromised by negligence in transcription. The use of incorrect terminology, omission of dictated information, insertion of information that is not dictated, and errors in patient identification come under the category of critical errors. Even antonyms â€“ terms that sound-alike â€“ have the potential to cause serious errors in patient documentation and care. A few pertinent examples:
- Aphagia – Incapacity to eat / Aphakia – nonexistence of the lens of the eye
- Cirrhosis – chronic disease of the liver / Psoriasis – inflammatory skin disease
- Eurhythmia – harmonious body relationships of the separate organs / Arrhythmia – loss of rhythm.
- Sycosis – pustular folliculitis, espcially of the bearded area / Psychosis – mental or behavioral disorder.
- Hypertension – high blood pressure / Hypotension – low blood pressure
- Bradycardia – slow pulse rate / Tachycardia – fast pulse rate
Critical errors could also occur in relation to the description of the patientâ€™s condition or a prescription. For example:
Dictated: The patient has not used amphetamines for at least four to five months
Transcribed: The patient has used amphetamines for at least four to five months (omission of the word â€˜notâ€™)
Dictated: The patientâ€™s risk factors include tobacco use, age, diabetes, and hypertension
Transcribed: The patientâ€™s risk factors include tobacco use, diabetes, and hypertension (omission of the word â€˜ageâ€™)
Such errors can even prove fatal. Avoiding these issues is possible by opting for reliable medical transcription services. With electronic health records becoming mandatory, the best way to avoid database errors and ensure accurate, consistent and timely documentation, is to outsource your medical transcription to an established and experienced medical transcription company.