Primary Care Coding 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 its accuracy.

A disclaimer on a medical record may lead a patient to believe 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 warns 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.