Back in October of 2002, I had a job in Rochester, New York transcribing dictation in my home for several of the providers in the surgical practice where I also worked as a nurse. Late one night, when the taped dictation had kept me exhausted at my computer for many hours, I finally reached the last letter on the last patient. On the tape, the doctor described how "Mrs. Smith" was found to have a certain condition and that she had opted to have surgery to correct it.
The next day, I took the transcribed dictation into the office and it was placed in the patient's chart. That next week, I assisted that same doctor who had dictated the letter. During the shift, we saw Mrs. Smith. The doctor examined her and they discussed her condition. Afterward, the doctor pointed out to me that somehow an office note had found its way into Mrs. Smith's chart... it detailed her condition and that she had opted for surgery; but the note was written a week before the patient had been seen!
But Mrs. Smith hadn't been seen for three years! The description in the chart note was accurate, except it said she opted for a surgical solution; in reality (or should I say this reality), the patient had opted for conservative treatment and not the surgical option.
Why was the letter dictated to me on the tape detailing a patient who hadn't yet been seen? And how could it have been correct in her diagnosis when the patient hadn't yet been seen?
