Health organizations are required to protect patient privacy under the guidelines set forth by the Health Insurance Portability and Accountability Act (HIPAA). Medical transcription services utilize secure servers and encrypt files to protect against privacy breaches, but doctors can easily violate the HIPAA Privacy Rule, create poor audio quality dictations and cause transcription errors when dictating from “anywhere.”
Protecting Patient Privacy and HIPAA Compliance
Physicians who transmit patient data electronically must comply with the HIPAA privacy rule to protect patient privacy. The Office of Civil Rights Privacy Rule describes “protected health information” (PHI) as being “individually identifiable information” that is transmitted by any media between the physician and his business associates within or outside the HIPAA-covered entity.
Therefore, if a physician is dictating a clinic note in the hallway outside the exam room and that information can be readily overheard by other patients, the doctor is not HIPAA compliant. If the physician uses a digital voice recorder without password protection or encryption and the recorder is left unsecured, this would also be a HIPAA violation. Doctors should take steps to ensure HIPAA compliance when dictating.
Digital Voice Recorders and Poor Quality Audio
Portable devices such as digital voice recorders and mobile phones, when used in public places, pick up background noise that obscures the dictator’s voice. Even simple movement of the recorder can cause static; and a doctor dictating in a car might as well be dictating in a wind tunnel if he has the window down or AC going. Dictating on the move increases the chances of background noise, changes in volume, and other interruptions that compromise sound quality. These same distractions are likely to result in poor dictation habits and incomplete dictations.
Dictation Errors Become Transcription Errors
While dictating on the move can seem convenient to the busy physician, it is not the best way to improve accuracy and rarely results in organized and concise medical documents. When on the move, physicians are not likely to have ready access to necessary patient information which leads to misinformation and/or incomplete dictations. Rushing from one location to the next with recorder in hand, breathlessly dictating amid heels clicking and doors squeaking, is a poor dictation habit.
Dictation practices that follow a routine will save time, not those that are crammed in between other activities. Not only does dictation multi-tasking lead to transcription errors, it also leads to the possibility of recording personal conversations and even restroom visits when distracted physicians accidentally leave their recorders on.
Mobile Dictation for Emergencies Only
Modern technologies provide physicians many options for dictating, but dictating on the go should be reserved for emergencies only. Stat dictations that need to be done immediately for the welfare of the patient are often called in to a service and are not done with the daily dictations.
For everyday dictating, it is much more efficient to establish a routine. This will save time, protect patient privacy, and result in quality medical documents done right the first time. Very few physicians are trained in the art of dictation, but it is a valuable skill for the busy physician to master.
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