Transcript Dictation Guidelines for Physicians Adherence to these

Literary Escapades of Internship…
Rachel Boykan, MD
Assistant Professor of Pediatrics
Pediatric Hospitalist
Stony Brook University Department of
Pediatrics
July 29, 2009
1. At the beginning of the dictation, take the deepest breath you possibly can and
then try to dictate the entire report before you have to inhale again.
2. When dictating a particularly difficult word or phrase, please turn your head
and speak directly into your armpit.
3. If you have to sneeze or cough suddenly, please remove your head from your
armpit and sneeze or cough directly into the microphone.
4. If you must eat while you dictate, please stay away from foods such as
marshmallows, bananas, and pudding; apples, pretzels, and celery are much
better choices.
Copyright 2005-2006, Copied with Permission from the web site,
"Patients and Medical Transcription" at http://www.mt-stuff.com
5. Please do not stop dictating when you yawn; it throws off our rhythm.
6. Do not stop dictating in the event of a minor background noise such as an office
party, the janitor’s vacuum cleaner, a screaming infant, etc.; again, it throws off our
rhythm.
7. Talk as fast as you possibly can. Fair is fair, after all, and we type as fast as we can!
8. Dates of admission and discharge are not important for old H&Ps or discharge
summaries.
9. Abbreviate whenever possible. Everyone loves a mystery and we are trying to
learn new skills, such as mind-reading.
10. Finally, be sure to wait until the end to tell us what kind of report you are
dictating, or to "scratch" this dictation since it was already dictated.
Copyright 2005-2006, Copied with Permission from the web site,
"Patients and Medical Transcription" at http://www.mt-stuff.com
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“This is an 8 year-old child accompanied by her
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“Her fourth toe cramps and she has to take off her
shoe and at times rub her foot until it goes away”
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mother, who appears playful and interactive”
“This is an evaluation of an 11 year-old girl who
suffered a fall today while ice-skating on her left
wrist”
“The patient occasionally gets a rash on her neck
which she has had for some time”
http://pages.sbcglobal.net/kellyratzlaff/kellyratzlaff/bloopers.htm
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A dictated summary is a written document and is
part of the medical record
It may be used for medico-legal purposes
What you say in to the microphone; what the
transcriptionist hears, is what is typed by the
transcriptionist
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Organize your data before starting transcription
Dictate in a secure, quiet area
Speak clearly, loudly and slowly
◦ Remember that the transcriptionist cannot read
your facial expressions, ask you to repeat
yourself or clarify a statement
Always state and spell your name and the name of
the patient you are documenting care for
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State the work type clearly
Be aware of possibly misunderstood words and
spell them, give hints
◦ AB duction vs AD duction, hyPER tension vs hyPO
tension
Never abbreviate medications; spell uncommon
drugs
Clearly state lab values, taking care that they don’t
run in to each other
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Use English
Speak as if you were writing
◦ Not texting
◦ Not sending e mails
◦ Not sending pages
Use subjects, nouns, verbs, etc.
Avoid colloquialisms/verbiage of sign-out
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“neuro-wise”
“Mommy states that…”
“as mentioned before,” “as I said,” “to recap…”
“positive red reflex”
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Speak clearly!
Be organized
◦ Use an outline if you need to
Be succinct, summarize - don’t record all the
details
Use dates, not days of the week
Avoid too much commentary or discussion that
does not apply to final story
Follow standard format and include a physical
exam!
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“The patient had pain when she saw me for several
months in November”
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“Bowel movements have remained stable with good
appetite”
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“Skin is, oh, well, uh, just take the skin off”
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“Her mother looked at her ears today and brings
them in today to be checked”
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“External genitalia revealed normal testes and
normal penis bilaterally”
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HPI
“During her initial stay on the pediatric floor, she continued to develop
labored breathing, and there was a concern about respiratory failure, so
she was transferred to the pediatric ICU for further care. In the ICU, the
patient had a relatively uneventful stay. She continued to require oxygen
and had transient desaturations on facemask down to 70 – 80%. These
episodes lasted several seconds and would resolve immediately with
stimulation of the patient, either by tactile stimulation or by suctioning.
The patient had a positive RSV swab and negative influenza. She
continued to have a fever, and subsequent chest x-ray on 5/20 showed
a focal airspace consolidation on the left lower lobe. However, in light of
her ______ improvement, this was felt to be secondary to RSV rather than
a bacterial process. She was not continued on her antibiotics upon
admission. Currently, the patient is on 2 liters nasal cannula and
displaying no increased work of breathing. Dr. x, the patient’s primary
attending, on 5/21, has commented that from a respiratory standpoint,
she looks better than her baseline.”
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ADMISSION DIAGNOSIS: Asthma exacerbation and bronchopneumonia
HISTORY OF PRESENT ILLNESS: A 4- year-old female with a history of asthma was admitted for
asthma exacerbation. The patient had an increase of wheezing over the past 2 days. The day
before the admission, the patient’s family noted the symptoms worsened and brought to ER. In
the ER, the patient received 3 nebs and steroid and minimal improvement and had developed
hives to the Atrovent that resolved with Benadryl.
HOSPITAL COURSE: The patient was admitted to the floor because the patient needed
continuous nebs and still had mild retractions and was transferred to PICU for 02 saturation
being less than 90 and on oxygen therapy. The patient also had a chest x-ray, which had
shown possible bronchopneumonia. The patient also was having generalized abdominal pain
focused. The patient, in PICU, started on IV antibiotics, ceftriaxone. The patient stayed in PICU
for 1 day. On 03/25, the patient was transferred back to the floor. Pulmonary was consulted,
recommended to add azithromycin along with Singulair and Flovent. The patient continued to
receive total of 4 days of ceftriaxone and azithromycin. The patient was doing well, satting well
on room air 92-94%. The patient was tolerating p.o. The patient was stable to discharge home.
The patient was discharged to home.
FINAL DIAGNOSES:
◦ 1. Asthma exacerbation
◦ 2. Bronchopneumonia
DISCHARGE MEDICATIONS: Flovent 110 mcg bid, albuterol, Singulair 4 grams po at bedtime,
ampicillin 800 mg po bid for additional 5 dys, Augmentin 300 mg po daily for additional 5
days.
DISCHARGE INSTRUCTIONS: The patient had a follow-up pulmonary clinic appointment within
1-2 weeks and PMD appointment on Monday. The patient was discharged home.
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CC: Fever, rule out sepsis
HPI: The patient is a 3-week-old male ex-NICU stay for 15 days for
intrauterine growth retardation, respiratory distress on CPAP and nasal
cannula, with feeding issues on NG feeding, born at 39 weeks,
transferred from St. x hospital. The patient has an unknown genetic
abnormality, follows with genetics; has grade III hypospadias, follow up
with pediatric surgery; has a right undescended testicle; cholestasis,
jaundice, on Actigall, follows with pediatric GI; a left choroid plexus cyst,
sees neurology, who presented with a 3-day history of abdominal pain,
hard stools and no bowel movement for 24 hours. Mom went to the
PMD, who was instructed to give prune juice on 06/04 and the patient
had a stool within 24 hours. The patient has been having wet diapers of
3 per day but has decreased from a baseline of 6 wet diapers per day.
The patient was having positive congestion and rhinorrhea for a day. The
patient had a low-grade temperature of 100.9 tympanic, contacted PMD
and was sent in to the ER for evaluation. There was a positive sick
contact at home. Mother was sick and the patient was transferred to Y
Hospital.
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CC: Fever, cough, abdominal distention
HPI: The patient is a 20-month-old male, full-term, normal
spontaneous vaginal delivery with no significant past medical
history, sent from X Hospital for possible ileus. The patient started
to have fevers on Monday at 102 degrees, cough, sent home with
hydration. From Tuesday to Thursday, the patient was doing fine but
did get some Tylenol for fever yesterday. Friday, the day of
admission, the patient went to clinic for vaccination and found to
have a distended abdomen. The patient transferred to x Hospital for
further evaluation. The patient did not have any bowel movement
today but had been having bowel movements the past couple of
days. The patient’s consolable when coming to the floor. No sick
contacts were reported.
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CC: Trauma
HPI: This is a 7-year-old male,….
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Dictations are an important and legal written part
of the chart
They convey the most important information about
an admission
They must be written clearly
With practice and attention to the basic rules they
can be done easily and quickly
Please do them within 30 days of discharging the
patient!