Dear colleagues,

During clinical documentation review, we found a number of physicians using a dragon dictation disclaimer as part of the electronic health record documentation process.

As you know, being a treating physician, you are legally and professionally responsible to confirm notes are accurate and reliable before entering your electronic signature into Epic/oneChart electronic health record. Using a disclaimer regarding the reliability of the dictation is not advised and it does not afford you any legal protection. In addition, the dictation disclaimer brings further attention to potential errors in your note if evaluated from a medical legal standpoint.

Examples of these phrases include “These notes were produced using voice recognition technology, and some typographical errors may be present, despite our best efforts with proofreading” or “This dictation was prepared using Dragon Medical voice recognition software. As a result, errors may occur. When identified, these errors have been corrected. While every attempt is made to correct errors during dictation, errors may still exist.”

These phrases should be removed from your note templates and smart phrases. Thank you for helping us with our continued effort in clinical documentation improvement.

If you have questions or concerns, please contact Dr. Zimmie, Dr. Tu or Dr. Beydoun.