"Dictated but not read": Unreviewed clinical record entries may pose risks

Many physicians dictate reports or chart entries in the course of providing medical services. In some cases, the transcribed reports or entries are marked “dictated but not read” and entered into the medical record or forwarded to the referring physician without prior review by the dictating physician. The report or entry may be reviewed and authenticated several days later or not at all, in which case the “dictated but not read” notice remains on the clinical record.

Marking transcribed reports or entries “dictated but not read” alerts readers that the author has not yet reviewed the transcription for accuracy. It prevents delays in the report or entry being included on the patient’s chart, thereby facilitating ongoing patient care. However, the practice also gives rise to some medico-legal risks for the author and can create uncertainty for those relying on the transcribed information when providing patient care. These concerns apply both when dictation is transcribed manually and when using speech recognition software.

Record-keeping requirements

Physicians should maintain medical records in accordance with applicable legislation and institutional and regulatory authority (College) policies. Those policies and legislation may require physicians to review and sign dictations within a specified period of time. Some hospital policies may include guidance or limitations on the use of the “dictated but not read” notation. Physicians who fail to comply with applicable record-keeping requirements may be subject to disciplinary action by their hospital, health authority, or College.

Medico-legal risks

A significant risk associated with the practice of marking reports or entries “dictated but not read” is the possibility that incorrect information becomes part of the patient’s medical record indefinitely. The incorrect information could be relied upon by other physicians when making treatment decisions, increasing the risk of a patient safety incident. This could lead to a legal action involving the dictating physician and possibly the subsequent treating physician.

A patient who is injured as a result of an error in a dictated and unreviewed report may launch a legal action claiming that the physician who made the dictation was negligent. In this situation, the patient would have to establish that the error in the report was a breach of the standard of care on the part of the dictating physician. When a physician knows that their unreviewed notes will be relied on by other practitioners, a court could expect the physician to meet a high standard of care with respect to those notes. This might include an expectation that the initial dictation was error-free or that the notes were promptly reviewed.

The time the report remained unreviewed, and the reason it was unreviewed for that period, will likely be important in determining a physician’s exposure to liability. In most cases it is unlikely that administrative convenience or efficiency will be accepted as a legitimate rationale for failing to ensure that a transcribed report is reviewed for accuracy and finalized within a reasonable time.

The transcriptionist will also likely bear some responsibility for the patient’s injury resulting from a negligently transcribed dictation. As well, the physician who relied on a report that she or he knew had not been reviewed by the dictating physician might also be named in the legal action. The court will determine whether it was negligent for that physician to rely on the unreviewed report based on the specific facts and circumstances of the case.

Medical records in legal proceedings

Proceedings are often brought many years after the advice or treatment was provided and a physician may not have an independent recollection of the patient. For that reason, accurate medical records are often a physician’s best defence. Conversely, inaccurate or incomplete records can be highly detrimental to a physician’s defence.

The practice of using “dictated but not read” notations may result in a physician being confronted with a record in the course of legal proceedings and recognizing only then that it does not accurately reflect the care provided or the patient’s condition. A court may draw an adverse inference against a physician for any attempt to challenge the accuracy of the record.

Risk management considerations

• Avoid including unreviewed dictated reports or entries in medical records.
• In circumstances where it is necessary for a transcribed but unreviewed report to be included in the record, ensure that the report indicates that it has been “dictated but not read” and, at the first opportunity and within the timeframe required by hospital or health authority rules and applicable legislation, review the transcribed report to ensure its accuracy.
• Contact the author for clarification if you are relying on a record marked “dictated but not read” and where serious consequences could result from an error in that report or where there is ambiguity in the entry.
• If you find an error in an entry or report you dictated, notify any practitioners you can reasonably assume have relied on that entry or report, and sign and date an addendum that preserves the original record but clearly shows the corrections made.

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.