Doctors who dictate notes 'could be missing vital patient health issues'

22 May 2012

Doctors could be reducing the level of healthcare that they are providing their patients by dictating their notes, a new study has suggested.

Researchers from Brigham and Women's Hospital (BWH) have highlighted that dictating findings can reflect a worse quality of care than other forms of structured documentation.

The team analysed 18,569 visits by 7,000 patients with coronary artery disease and diabetes, with 20 doctors dictating their notes, 68 medical professionals using structured documentation and another 146 doctors typing free-text notes.

According to the study, quality of care was much lower for doctors who dictate when it came to recording notes about antiplatelet medication, tobacco use documentation and diabetic eye exam compared to the two other documentation measures.

Jeffrey Linder, associate professor of medicine at BWH and Harvard Medical School, commented: "Doctors who dictate may not be paying as close attention to information and alerts in the electronic health record that are important for patient health."

Patients are advised to stick with doctors when it comes to getting their bodies checked over though, after a recent study by Balance Activ found that one in four people have misdiagnosed an illness after following advice provided over the web.

Posted by Philip Briggs


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