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 wwww wwww wwww.... AAAA AAAA MMMM TTTT.... oooo rrrr gggg

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

Contact 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. MedQuist Inc. Corporate Offices 1000 Bishops Gate Blvd. Suite 300 Mount Laurel, New Jersey Phone: Fax: Sponsor