Podiatry Coding & Billing Alert

Question: One of the physicians at our practice uses dictation software, and the vendor for the software suggested adding a disclaimer so patients know that the dictation software isn’t completely foolproof, and some inaccuracies may occur. Is this advisable?

Florida Subscriber

Answer: Providers are responsible for medical record documentation. Disclaimers like the one you mention don’t absolve providers of that responsibility. When a physician signs a medical record, they are authenticating it and therefore attesting to the accuracy therein.

A disclaimer on a medical record may lead a patient to believe that they’re receiving indifferent care from a provider — or be a red flag for an attorney reviewing documentation while considering a malpractice suit, said Jeffery A. Woods, JD, director of risk education at SVMIC, in online legal analysis. Woods warned that disclaimers should not be used because they do not lessen a provider’s liability, and may, in fact, create problems by drawing attention to a provider’s willingness to accept inaccuracies in the documentation of patient care. “Not only does this practice fail to favor physicians, but prosecuting attorneys actively seek out doctors who employ it. Therefore, it is imperative for physicians to exercise extreme caution in its use,” says Terry Fletcher, BS, CPC, CCC, CEMC, SCP-CA, ACS-CA, CCS-P, CCS, CMSCS, CMC, QMGC, QMCRC, QMPM, CEO/president at Terry Fletcher Consulting Inc. and podcaster at The CodeCast Podcast.