Transcript Document
Dictation Best Practices
A Guide for Physicians
Dictation Best Practices
A Guide for Physicians
Presented
by the
American Association for Medical Transcription
Sponsored by
Why Do You Dictate?
Documentation is an Essential
Ingredient of Good Medical Care
Good Documentation
Accurate
Complete
Available
When Needed
Quote or Quill
Dictation is an effective and
economical way to convey the
patient’s story
The Challenge
Communicate clearly and succinctly
Partners in Quality
Medical Transcriptionists are
documentation experts and
your partner in creating the
required record of care—
accurately and efficiently.
Impact of Dictation
Documentation errors
Patient Safety
Sentinel Events
Turnaround Time
Costs
Patients at Risk
Poor dictation can result in the
omission of very important words such
as “no” or “non”, as in “there is (no)
malignancy identified”
US Leads in Medical Errors
“Thirty-four percent of U.S. patients received
wrong medication, improper treatment or
incorrect or delayed test results during the last
two years, the Commonwealth Fund found.”
US Leads Way in Medical Errors, S. Heavy, Common
Dreams, November 23, 2005
View of the Courts
According to the Wisconsin Supreme Court
“We hold only that hospital records bear
such an unusual indicia of reliability and
trustworthiness that … such records satisfy
the confrontation clause.”
Good Dictation
Improves communication among
caregivers
Promotes patient safety
Reduces turnaround time from
dictation to charting
Ensures uncompromised reports
as legal documents
Poor Dictation
Leads to errors in transcription
Puts patients at risk
Slows and/or reduces
reimbursement
Impacts timely delivery of care
Increases administrative and
transcription costs
Problematic Dictation
Incorrect verbiage or grammar
Rapid speech
English as a second language
Articulation
Insufficient volume
Background noise
Incorrect or insufficient patient information
Turnaround Time
Quality patient care demands shorter
turnaround time
Problematic dictation can double or
triple time spent transcribing
Several problematic reports
can affect timely delivery of
all reports
Costs
Inferior dictation increases
administrative costs
Inadequate dictation decreases or
delays reimbursement
Poor dictation can increase
turnaround time,
delaying treatment
Dictation
Requires special attention to
clarity and style
No visual clues (lip movements,
facial expressions)
Asynchronous communication
Lacks flow and rhythm of
conversations
More difficult to comprehend
Speech Recognition
Realizing higher adoption rates
Incapable of completely replacing
transcriptionists
Unable to interpret vast majority of
dictators
Requires more attention to
organization and articulation
Environment
Monitor background
distractions such as voices,
telephone ringing, and/or
music
Avoid side conversations
Background Noise
He had three recent _____ procedures
and is seeing a cardiologist.
Organization
Organize data before
dictating
Follow established templates
Disorganized Dictator
Chest wall showed tenderness on
pressing on the right lateral and anterior
ribs area. Back showed kyphosis.
Heart S1, S2.
Equipment
Refer to tip sheets for proper use of
dictation equipment
Use correct hand-held settings to avoid
clipped words
Hold the mic the proper
distance from the mouth
Too Close to Microphone
At that time, her chest x-ray ____ a new
finding of ______ atelectasis which I felt
was due to her residual RSV bronchiolitis.
“Puffing” the Mic
Babinski and no clonus ____ in the
upper and lower extremities. Her motor
is normal. Her sensation is decreased in
the C6 distribution on the left. She does
have a positive Tinel sign over the
median nerve but a negative Phalen sign.
Demographics
Key identifying information
when prompted
State and spell the patient’s
name
Include at least one other
patient identifier (i.e., birth
date or MRN)
State the date of service
Courtesy
Avoid eating and chewing
gum
Pause while yawning,
coughing or sneezing
Remember! We can hear
what you wouldn’t want us
to hear!
Yawning
Back pain ____________. Past
medical history is negative.
Surgery negative.
Speech
The dictator’s speed and poor
articulation were cited as being
the most frequent causes of
problematic dictation.
Key Syllables
“No” or “known”
ABduction or ADduction
hyPO or hyPER
Abbreviations
Avoid uncommon abbreviations
Use abbreviations from facility’s
approved list
Give clues when dictating common
abbreviations
BMP versus BNP
CNS versus C&S
Numbers
Dictate numbers clearly and
succinctly
Differentiate “fifty” and “sixty”
(e.g. five-oh, six-oh)
Delineate vital signs and lab
values with test names
Running Numbers Together
Temperature is 98.3, 120/60, 105,
16.
Medications
Carefully dictate
medication names and
dosages, especially those
with sound-alikes
(e.g. Endal, Inderal;
MiraSept, Mircette)
Feedback
Return notations on blanks
or incorrect areas of the
document to the
transcription staff in order
to prevent errors in the
future
Dictation Tool Kit
Dictation Fact Sheet
Dictation 101
Model Policies and Procedures
Sample Q Cards
Feedback Letter
Tip Sheet
www.AAMT.org
The Bottom Line
Good quality dictation
and transcription is winwin for the patient, the
caregiver, and the
facility’s bottom line
Contact
American Association for Medical
Transcription
www.aamt.org
800-982-2182
Sponsor
MedQuist is the leading provider of clinical document
workflow solutions. MedQuist provides document workflow
management, digital dictation, speech recognition, dictation
devices, Web-based transcription, electronic signature,
medical coding and outsourcing services.
MedQuist Inc.
Corporate Offices
1000 Bishops Gate Blvd.
Suite 300
Mount Laurel, New Jersey
08054-4632
Phone: 800-233-3030
Fax: 856-206-4020