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A: Despite its prevalence, this is really a poor practice. Phrases such as “Signed, but not read” or “Dictated, but not read” often show up in physicians’ office progress notes. While truth and honesty are admirable, one has to wonder what is accomplished by inserting these phrases. Will use of such phrases actually “red flag” medical dictation errors for plaintiffs’ attorneys and imply that the physician cared little about the accuracy of the permanent medical record? Transcribed materials routinely contain errors and omissions. Granted, the task of reading and correcting one’s own transcription is tedious, at best, and often seems like a waste of time. Some physicians may read and edit only selected reports on specific patients and ignore the rest. But, we live in a world where “medical errors” seem to lurk behind every bush. The practice of signing, but not reading, transcription not only perpetuates errors, but exacerbates the risks associated with technology. A patient’s chart serves not only as a historical record of diagnoses and treatment, but also as a means to communicate with others involved in that patient’s care. How can we tolerate passing along incomplete or erroneous information when the means to achieve accuracy are literally at our fingertips? Perhaps the best reason to ensure the accuracy of transcribed reports is patient safety. One cannot know when erroneous information will cause harm. Another very practical reason to review and edit transcription is evident if you place yourself on the witness stand, under oath, answering this question: “Doctor, isn’t the poor quality of your medical record indicative of your own sloppy practices?”
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