Dictation Best Practices

1
Dictation Best Practices

• A Guide for Physicians

2
Dictation Best Practices

• A Guide for Physicians

Presented by theAmerican Association for
Medical Transcription
Sponsored by
3
Why Do You Dictate?

• Documentation is an Essential Ingredient of Good
  Medical Care

4
Good Documentation

• Accurate
• Complete
• Available When Needed

5
Quote or Quill
Dictation is an effective and economical way to
convey the patients story
6
The Challenge

• Communicate clearly and succinctly

7
Partners in Quality

• Medical Transcriptionists are documentation
  experts and your partner in creating the required
  record of careaccurately and efficiently.

8
Impact of Dictation

• Documentation errors
• Patient Safety
• Sentinel Events
• Turnaround Time
• Costs

9
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
10
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
11
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.
12
Good Dictation

• Improves communication among caregivers
• Promotes patient safety
• Reduces turnaround time from dictation to
  charting
• Ensures uncompromised reports as legal documents

13
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

14
Problematic Dictation

• Incorrect verbiage or grammar
• Rapid speech
• English as a second language
• Articulation
• Insufficient volume
• Background noise
• Incorrect or insufficient patient information

15
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

16
Costs

• Inferior dictation increases administrative costs
• Inadequate dictation decreases or delays
  reimbursement
• Poor dictation can increaseturnaround time,
  delaying treatment

17
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

18
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

19
Environment

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

20
Background Noise
He had three recent _____ procedures and is
seeing a cardiologist.
21
Organization

• Organize data before dictating
• Follow established templates

22
Disorganized Dictator
Chest wall showed tenderness on pressing on the
right lateral and anterior ribs area. Back
showed kyphosis. Heart S1, S2.
23
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

24
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.
25
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.
26
Demographics

• Key identifying information when prompted
• State and spell the patients name
• Include at least one other patient identifier
  (i.e., birth date or MRN)
• State the date of service

27
Courtesy

• Avoid eating and chewing gum
• Pause while yawning, coughing or sneezing
• Remember! We can hear what you wouldnt want us
  to hear!

28
Yawning
Back pain ____________. Past medical history is
negative. Surgery negative.
29
Speech
The dictators speed and poor articulation were
cited as being the most frequent causes of
problematic dictation.
30
Key Syllables

• No or known
• ABduction or ADduction
• hyPO or hyPER

31
Abbreviations

• Avoid uncommon abbreviations
• Use abbreviations from facilitys approved list
• Give clues when dictating common abbreviations
• BMP versus BNP
• CNS versus CS

32
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

33
Running Numbers Together
Temperature is 98.3, 120/60, 105, 16.
34
Medications

• Carefully dictate medication names and
  dosages, especially those with sound-alikes
• (e.g. Endal, Inderal
• MiraSept, Mircette)

35
Feedback
Return notations on blanks or incorrect areas of
the document to the transcription staff in order
to prevent errors in the future
36
Dictation Tool Kit

• Dictation Fact Sheet
• Dictation 101
• Model Policies and Procedures
• Sample Q Cards
• Feedback Letter
• Tip Sheet
• www.AAMT.org

37
The Bottom Line
Good quality dictation and transcription is
win-win for the patient, the caregiver, and the
facilitys bottom line
38
Contact

• American Association for Medical Transcription
• www.aamt.org
• 800-982-2182

39
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 [phone]