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Dictation Best Practices. A Guide for Physicians. Presented by the American Association for Medical Transcription. Dictation Best Practices. A Guide for Physicians. Sponsored by . Why Do You Dictate?. Documentation is an Essential Ingredient of Good Medical Care. Good Documentation.

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Dictation best practices

Dictation Best Practices

A Guide for Physicians


Dictation best practices1

Presentedby theAmerican Association for Medical Transcription

Dictation Best Practices

A Guide for Physicians

Sponsored by


Why do you dictate
Why Do You Dictate?

Documentation is an Essential Ingredient of Good Medical Care


Good documentation
Good Documentation

  • Accurate

  • Complete

  • Available When Needed


Quote or quill
Quote or Quill

Dictation is an effective and economical way to convey the patient’s story


The challenge
The Challenge

Communicate clearly and succinctly


Partners in quality
Partners in Quality

Medical Transcriptionists are documentation experts and your partner in creating the required record of care—accurately and efficiently.


Impact of dictation
Impact of Dictation

  • Documentation errors

  • Patient Safety

  • Sentinel Events

  • Turnaround Time

  • Costs


Patients at risk
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
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
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
Good Dictation

  • Improves communication among caregivers

  • Promotes patient safety

  • Reduces turnaround time from dictation to charting

  • Ensures uncompromised reports as legal documents


Poor dictation
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
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
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
Costs

  • Inferior dictation increases administrative costs

  • Inadequate dictation decreases or delays reimbursement

  • Poor dictation can increaseturnaround time, delaying treatment


Dictation
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
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
Environment

  • Monitor background distractions such as voices, telephone ringing, and/or music

  • Avoid side conversations


Background noise
Background Noise

He had three recent _____ procedures and is seeing a cardiologist.


Organization
Organization

  • Organize data before dictating

  • Follow established templates


Disorganized dictator
Disorganized Dictator

Chest wall showed tenderness on pressing on the right lateral and anterior ribs area. Back showed kyphosis. Heart S1, S2.


Equipment
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
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
“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
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
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
Yawning

Back pain ____________. Past medical history is negative. Surgery negative.


Speech
Speech

The dictator’s speed and poor articulation were cited as being the most frequent causes of problematic dictation.


Key syllables
Key Syllables

  • “No” or “known”

  • ABduction or ADduction

  • hyPO or hyPER


Abbreviations
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
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
Running Numbers Together

Temperature is 98.3, 120/60, 105, 16.


Medications
Medications

Carefully dictate medication names and dosages, especially those with sound-alikes

(e.g. Endal, Inderal;

MiraSept, Mircette)


Feedback
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 Tool Kit

  • Dictation Fact Sheet

  • Dictation 101

  • Model Policies and Procedures

  • Sample Q Cards

  • Feedback Letter

  • Tip Sheet

    www.AAMT.org


The bottom line
The Bottom Line

Good quality dictation and transcription is win-win for the patient, the caregiver, and the facility’s bottom line


Contact
Contact

American Association for Medical Transcription

www.aamt.org

800-982-2182


Sponsor
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 300Mount Laurel, New Jersey08054-4632Phone: 800-233-3030 Fax: 856-206-4020


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