“Let me count the ways.”

EDITOR’S NOTE: Dr. Remer reported on this topic during the most recent edition of Talk Ten Tuesdays.

I have been doing a project evaluating emergency department documentation, and many of the emergency providers utilize voice recognition. As such, illegibility has been replaced by unintelligibility.

I am not proposing that providers spend all day generating a single record, but they should want their documentation to reflect the excellent care they are providing. If I received a legal notice or read an article that had the kind of issues that some of these documents have, I would question the competence of the author. No one wants to have their medical acumen questioned because of shoddy documentation. Furthermore, no one wants harm to come to a patient because documentation was not accurate. There is no way around this: providers must read and edit their transcription.

Let me share some of the common errors I am seeing, in no particular order of importance. Some errors are not worth correcting, but some are critical, and each provider should be made to edit their document after the fact. I liken it to having “right” accidentally replaced with “left;” clinical documentation improvement (CDI) professionals should give the provider an opportunity to set the record straight and correct their documentation.

I also see numerical errors. This can be clinically significant if, for instance, a consultant is recommending a course of action and a dosage is off by tenfold. I recall reading of a “3-year-old woman” whose son, a cardiologist, brought her in for evaluation.

Sometimes when you are dictating, you stutter or falter, and the voice recognition captures a word or a syllable twice, causing duplication. This is usually not clinically significant, but it does give the appearance of carelessness.

This next commonly seen error can be very significant. Voice recognition (VR) has become very sophisticated, but technology doesn’t intuitively understand meaning. It has frequency distributions so it can predict the correct “their,” “there,” or “they’re,” according to the words surrounding it. Sometimes, though, the VR just has no clue where you were going with your dictation, and it inserts whatever it thinks matches. This can result in nonsensical words, phrases, or sentences.

A patient in severe respiratory distress leaning forward to catch their breath can be found to “occasionally try potting,” or a patient might get “three milligrams of blood riding morning” (which was supposed to be Glyburide). Nonsense transcription can cause subsequent caregivers to skip over parts of a note that were supposed to have substantive information in them, because they just can’t decipher the meaning.

Redundancies and run-on sentences pose the same risk. Important information can get lost in the shuffle. Just as it may take you more time to curate your dictation to ensure accuracy, it may take someone significantly more time to try to sift through repetitive phrasing to try to glean the meaning. They may not even try. I know my brain gets frustrated trying to extract a cogent story from some documentation.

Sometimes the errors can be entertaining, and it’s a personal challenge to figure out where they come from. “Tonsil patient on smoking cessation” is presumably from “counsel patient on smoking cessation.” Unusual surnames or local facilities’ names may get mangled by untaught voice recognition programs.

Alternating pronouns can be distracting, and particularly vexing when the patient’s name is gender-neutral or foreign. It is acceptable to use “they” and “their” as gender-neutral pronouns now.

A more serious error type is omission. When you leave a word out or cut a sentence off, vital information may be absent. What procedure exactly was done at the outside hospital? If “she just (word missing) onto the floor” – did she slide or fall?

I can provide you with some interesting examples of errors that obscure or change the intent of the documentation. A common etiology is losing or inserting a negating word into a sentence. Giving a run-on list of pertinent positive and negative symptoms without appropriate punctuation can leave the reader scratching their head as to whether the fifth one WAS present, or whether you were documenting that it was NOT present?

As I wrote this article, I was trying to determine which sign of thought disorder sloppy voice recognition resembles, and I discovered it actually covers a multitude. Tangentiality, derailment, incoherence, neologisms, word approximations, circumstantiality, and paraphrasic errors abound. Your providers do not want to come across as psychotic!

Finally, having a disclaimer that says “it’s my voice recognition’s fault that there are mistakes in this documentation,” is not a valid excuse. It is the provider’s responsibility to ensure accuracy. And, for sure, no one should do what I saw one provider do: their disclaimer said (with their outside voice) that the note had not been proofread.

Feel free to print out my tip sheet for providers on my website, icd10md.com.


  1. Errors in numbers
    1.  A “3-year-old” whose son, the cardiologist, brings her in (for some reason, 3 and 30 are frequently substituted)
    2. “When” often becomes a “1”
  2. Duplicated words
    1. “However, he states that he he did fall”
  3. Nonsensical
    1. May not handle abbreviations well: Patient had no heart tones and PE a. (PEA)
    2. Occasionally try potting (tripoding)
    3. Noted that there was cooking lower the floor (which is likely, with the patient “slipped on and fell”)
    4. States this is a “60 has been ever”
    5. She takes 3 milligrams of “blood riding morning” (Glyburide every morning)
    6. He inhaled what he states “the nap rocks”
    7. “Cycle flexion” extension of the elbow
    8. Lorcet static lightheadedness
  4. Redundancy
    1. “Patient presents to ED for evaluation secondary to vomiting, with what appears to be fecal material. He presents with abdominal distention and intermittent episodes of pain and vomiting with a “history of BO,” and in the past he states has had abdominal distention with persistent vomiting…he states he has had persistent nausea vomiting for last two days and not sure if he ate something…..he states his abdomen is more distended than usual….”
    2. “Patient states that after being discharged from detox, he did go to hydrate medical and get some IV fluids but was told he was dehydrated when he was in detox and he tried to drink Gatorade and other fluids to keep hydrated”
  5. Run-on sentences; absent punctuation
    1. “The patient he is unable to provide interval history as she is not a reliable historian all history was obtained from patient’s husband who is here at the bedside”
    2. “Patient seen and evaluated with the patient does not present the room patient agitated asking to leave she is awake she is alert she is oriented to person place and time she is adamant about leaving the ED prior to having work-up…(goes on for the entire page)”
    3. “Pressure did not patient denies any preceding symptoms on exam she does have a 2 out of 6 systolic ejection murmur CPK was noted to be 1,300 and imaging revealing some pelvic fractures”
  6. Misunderstood words; malapropisms
    1. “Tonsil patient on smoking cessation”
    2. “Rake through” seizure (breakthrough)
    3. “Followed by Dr. To bilirubin replace the stent” (I don’t know what this doctor’s name really is – it probably sounds like “To bilirubin”)
    4. “No cry tears for SIRS/sepsis”
  7. Pronouns alternating between “he” and “she”
  8. Omissions of words or cut-off sentences. leaving us hanging
    1. “Patient does not recall how he”
    2. “She just onto the floor” (What did she just do? Fell? Slid?)
  9. Errors that change or obscure the intent of the documentation
    1. “I initially wrote for Rocephin, but with his allergy profile unclear, I will change this to history and am.” (What medication did the provider put the patient on?)
    2. Leaving out or splitting up a word that would negate the phrase (was diagnosed with scabies, which I think is not “in consistent”)
    3. “Husband denies seeing any focal neurologic deficit shows a facial droop or hemi body weakness”
    4. “Patient has history of COPD but was recently admitted for same with elevated troponin level.” The same, COPD, or the same presenting complaints?
    5. “Currently she has a heart rate in the 100s, when she arrived currently is in the 70s.”
    6. “States she had no back pain no dysuria hematuria no hemoptysis (does she have hematuria or not?)
  10. Multiple error types in the same sentence
    1. “No No McBurney but is felt nauseous”
    2. “Patient was seen in his cancer doctor’s office for an acute visit patient states that he’s had progressive pain in the left lateral chest wall and it extends up into his scapular area patient says that he received his treatment for his cancer and went away to Florida the pain become really bad he did take three oxycodone which is more in his normal dose and it did not help his pain at all patient also states she’s had worsening leg pain and weakness”

I have designed a tip sheet for providers, which you can obtain by going to my website, icd10md.com, under the “Free Pointers” tab.

Programming Note:

Listen to Dr. Remer live every Tuesday on Talk Ten Tuesday, 10-10:30 a.m. ET.

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Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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