Table 3. Error Types in Dictated Notes by Note Type and Processing Stage.
Note Type (No.) | Note Stage | Total Errors, No. | No. (%) | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Errors, General Typea | Errors, Semantic Typea | ||||||||||||||||||
Deletion | Insertion | Substitution | No. | Punctuation | General Englishc | Clinical Information | |||||||||||||
Enunciation | Homonym | Nonsense | Otherb | Medication | Diagnosis | Procedure | Symptom | Laboratory Test | Physical Examination | Imaging Test | Otherd | ||||||||
Discharge summaries (75) | SR | 3892 | 1395 (35.8) | 1031 (26.5) | 655 (16.8) | 5 (0.1) | 272 (7.0) | 186 (4.8) | 133 (3.4) | 215 (5.5) | 3314 (85.1) | 127 (3.3) | 76 (2.0) | 13 (0.3) | 60 (1.5) | 50 (1.3) | 30 (0.8) | 25 (0.6) | 197 (5.1) |
MT | 195 | 87 (44.7) | 36 (18.5) | 35 (17.9) | 0 | 5 (2.6) | 20 (10.3) | 9 (4.6) | 3 (1.5) | 133 (68.2) | 14 (7.2) | 9 (4.6) | 2 (1.0) | 7 (3.6) | 2 (1.0) | 14 (7.2) | 2 (1.0) | 12 (6.2) | |
SN | 163 | 74 (45.4) | 29 (17.8) | 29 (17.8) | 0 | 1 (0.6) | 19 (11.7) | 8 (4.9) | 3 (1.8) | 114 (69.9) | 6 (3.7) | 9 (5.5) | 2 (1.2) | 7 (4.3) | 2 (1.2) | 14 (8.6) | 2 (1.2) | 7 (4.3) | |
Office notes (83) | SR | 2513 | 875 (34.8) | 549 (21.8) | 608 (24.2) | 10 (0.4) | 178 (7.1) | 128 (5.1) | 41 (1.6) | 124 (4.9) | 2166 (86.2) | 55 (2.2) | 60 (2.4) | 27 (1.1) | 40 (1.6) | 15 (0.6) | 10 (0.4) | 8 (0.3) | 132 (5.3) |
MT | 128 | 39 (30.5) | 26 (20.3) | 39 (30.5) | 1 (0.8) | 11 (8.6) | 10 (7.8) | 2 (1.6) | 0 | 108 (84.4) | 1 (0.8) | 7 (5.5) | 2 (1.6) | 2 (1.6) | 1 (0.8) | 0 | 0 | 7 (5.5) | |
SN | 53 | 16 (30.2) | 17 (32.1) | 10 (18.9) | 0 | 6 (11.3) | 3 (5.7) | 1 (1.9) | 0 | 44 (83.0) | 0 | 5 (9.4) | 0 | 1 (1.9) | 1 (1.9) | 0 | 0 | 2 (3.8) | |
Operative notes (59) | SR | 1756 | 559 (31.8) | 620 (35.3) | 226 (12.9) | 13 (0.7) | 124 (7.1) | 77 (4.4) | 40 (2.3) | 97 (5.5) | 1393 (79.3) | 4 (0.2) | 39 (2.2) | 140 (8.0) | 8 (0.5) | 1 (0.1) | 5 (0.3) | 1 (0.1) | 165 (9.4) |
MT | 138 | 48 (34.8) | 37 (26.8) | 25 (18.1) | 1 (0.7) | 15 (10.9) | 9 (6.5) | 1 (0.7) | 2 (1.4) | 96 (69.6) | 0 | 5 (3.6) | 15 (10.9) | 4 (2.9) | 0 | 1 (0.7) | 1 (0.7) | 16 (11.6) | |
SN | 112 | 43 (38.4) | 35 (31.3) | 19 (17.0) | 1 (0.9) | 5 (4.5) | 6 (5.4) | 1 (0.9) | 2 (1.8) | 85 (75.9) | 0 | 4 (3.6) | 10 (8.9) | 2 (1.8) | 0 | 1 (0.9) | 1 (0.9) | 9 (8.0) | |
All notes (217) | SR | 8161 | 2829 (34.7) | 2200 (27.0) | 1489 (18.2) | 28 (0.3) | 574 (7.0) | 391 (4.8) | 214 (2.6) | 436 (5.3) | 6873 (84.2) | 186 (2.3) | 175 (2.1) | 180 (2.2) | 108 (1.3) | 66 (0.8) | 45 (0.6) | 34 (0.4) | 494 (6.1) |
MT | 461 | 174 (37.7) | 99 (21.5) | 99 (21.5) | 2 (0.4) | 31 (6.7) | 39 (8.5) | 12 (2.6) | 5 (1.1) | 337 (73.1) | 15 (3.3) | 21 (4.6) | 19 (4.1) | 13 (2.8) | 3 (0.7) | 15 (3.3) | 3 (0.7) | 35 (7.6) | |
SN | 328 | 133 (40.5) | 81 (24.7) | 58 (17.7) | 1 (0.3) | 12 (3.7) | 28 (8.5) | 10 (3.0) | 5 (1.5) | 243 (74.1) | 6 (1.8) | 18 (5.5) | 12 (3.7) | 10 (3.0) | 3 (0.9) | 15 (4.6) | 3 (0.9) | 18 (5.5) |
Abbreviations: MT, medical transcriptionist–edited notes; SN, signed notes; SR, automatic transcriptions by the speech recognition system.
Percentages are equal to the number of errors of each type divided by the total number of errors; percentages may not sum to 100 because of rounding.
Includes suffix, prefix, dictionary, and spelling errors.
Includes general English, stop word, and date errors.
Includes patient or physician identifier, interpretation, psychological test, and ??? (unintelligible or otherwise unclassifiable) errors.