Medical Transcription Lawsuit Exposes Inherent Dangers to “Care-then-Document” Model

 Article Publication:  Baldwin County jury hands down $140M settlement

This case exposes the liability of documenting after the physician patient encounter, which is the historical practice of medical transcription companies. The case also underscores the federal government’s assertion that widespread EHR use will result in a decrease in medical errors by virtue of the inherent safety measures within the EHR workflow that would have prevented this patient’s death. For example, orders do not get seen by nursing staff, let alone executed, unless they are signed by the doctor. Unfortunately, it is well known that EHRs slow doctors down, thus impeding the doctor’s ability to document in real time, which as this lawsuit implies, was a significant mistake with the hospital’s process.

Additional patient protection is afforded by the proper use of scribes since the typical scribe workflow is to document contemporaneously with the physician-patient encounter. Thus, the medical record is completed and signed by the doctor, prior to patient discharge. Proper scribe use adds another patient safety feature that, unlike doctors whose dictation may sound muffled or unintelligible by the medical transcriptionist who is listening on the other side,  doctors who work with medical scribes can be immediately queried by the scribe at the point-of-service. This dynamic dialogue is a compelling safety feature of the physician-scribe model that physicians using medical transcription, do not have.  Real time, onsite medical scribe documentation, alongside the physician, adds to increased operational productivity and patient safety protocols within the EHR environment.

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