tci Medicare Compliance & Reimbursement - 2024 Issue Q3

Reader Questions: Know The Facts About Disclaimers On Records

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? South Carolina 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 the accuracy therein. A disclaimer on a medical record may lead a patient to believe that they’re receiving indifferent...

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