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.
A Guide for Physicians
Documentation is an Essential Ingredient of Good Medical Care
Dictation is an effective and economical way to convey the patient’s story
Communicate clearly and succinctly
Medical Transcriptionists are documentation experts and your partner in creating the required record of care—accurately and efficiently.
“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
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.”
He had three recent _____ procedures and is seeing a cardiologist.
Chest wall showed tenderness on pressing on the right lateral and anterior ribs area. Back showed kyphosis. Heart S1, S2.
At that time, her chest x-ray ____ a new finding of ______ atelectasis which I felt was due to her residual RSV bronchiolitis.
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.
Back pain ____________. Past medical history is negative. Surgery negative.
The dictator’s speed and poor articulation were cited as being the most frequent causes of problematic dictation.
Temperature is 98.3, 120/60, 105, 16.
Carefully dictate medication names and dosages, especially those with sound-alikes
(e.g. Endal, Inderal;
Return notations on blanks or incorrect areas of the document to the transcription staff in order to prevent errors in the future
Good quality dictation and transcription is win-win for the patient, the caregiver, and the facility’s bottom line
American Association for Medical Transcription
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.
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