Physician Dictation Guide:
Page 1

A Hard Pill To Swallow

Dictating is an acquired skill. If you dictate, you might enjoy reading some of the “Dos” and “Don'ts” of dicating - if you can take it. Some have said it is a “real eye-opener.” In spite of the emphasis these days for speed and accuracy in “the electronic patient record,” most med schools seem to completely ignore the physician's role in the extremely important area of dictation technique. Rather, it seems most medical schools expect new doctors to learn dictation skills on their own and this thereby leaves everyone else to clean up the inevitable mess. Unfortunately, a physician usually picks up the dictation style of a mentor - and, if the mentor has them, all their mistakes, bad habits, etc., along with it.

Some physicians need to ask for help from their transcriptionist regarding dictation technique but, for whatever reason, cannot. We have therefore published this very basic set of guidelines to help those who may not want to ask for help. The following points are simple, basic guidelines to follow when dictating medical reports. They are certainly not complete. If you are a physician reading this and find that you do not already follow most of these guidelines, maybe you should review your dictation skills and ask for help from your transcriptionist if you need it. If you follow these recommendations, transcriptionists will be more likely to produce transcription of your dictation in an accurate and timely fashion.

Please . . .

• DO Learn about your recording equipment; how it works; how to maintain it. If you use a digital voice recorder, Medword has many manuals in PDF format available. Otherwise, you can usually find your machine's user's guide on the manufacturer's web site.
  
• DO Assemble any papers, reports, before you start dictating.
  
• DO Make sure you are in a quiet area so your dictation can be heard clearly by the transcriptionist.
  
• DO Identify yourself at the beginning of your dictation and state what dictation you are doing, i.e., what type of reports and the date you want reflected in the reports. (The day of patient examination, the date of your dictation, or the date the transcriptionist is actually transcribing the work.)
  
• DO Say “Hello” to the transcriptionist who will be transcribing your tape/digital audio file. It is surprising how many people who dictate fail to acknowledge the person who will be transcribing their dictation. Even if your tape/digital audio file is sent to a “transcription pool” and you therefore do not know who will be transcribing it, a short, friendly word at the beginning of each file can sometimes lift the spirits of whomever is transcribing your work. Many transcriptionists enjoy doing work more for someone who sounds friendly.
  
• DO Always state then spell full details of: addressees, their full name, proper mailing address; file numbers; reference numbers; patient record number; subject matter.
  
• DO Try to use the same phrases in each of your report types. Be consistent in the way you approach similar reports. Make sure you use the same headings whenever possible. This makes it easier to transcribe your work and lessens the chance of error.
  
• DO Speak clearly and at a regular pace.
  
• DO Pause slightly before speaking when starting your recorder and pause briefly before stopping recording. This prevents words from being “clipped.”
  
• DO Speak with inflection in your voice. Monotonal voices tend to put transcriptionists to “sleep.”
  
• DO Speak with your mouth at the recommended distance from your particular brand of microphone or recorder for optimum sound levels.
  
• DO Edit-out any errors you make, by rewinding and erasing them.
  
• DO Spell unusual words that may represent diseases, drugs, or procedures not normally found in the mainstream of your daily work or specialty.
  
• DO Always include punctuation, especially when starting new paragraphs.
  
• DO Include “open” and “close” quotation instructions.
  
• DO Have your dictation equipment serviced at least yearly. Putting it in for service during your vacation is a good time.
  
• DO Get a colleague's dictation tape/digital audio file and spend just one single hour trying to transcribe his/her dictation as a transcriptionist would. We absolutely guarantee it will be an eye-opener.
  

Continued . . .