Tips For Physicians. Dictation Device Handling Guide For Doctors

By Raj | Jul 23, 2007

Every transcriber starts his/her day with a prayer that all the work for that particular day should end up perfectly and that no issues should arise. However, his fate is not purely dependent on his/her work alone. A major chunk of that responsibility rests with the dictating physician.

Tips and Techniques for Dictating Doctors

A lot of tough scenes may arise on the part of the transcriber that he/she may want to convey to the physician but may stay put saying “let someone else bell the cat” and I am assuming that role of “someone else” here in a hope that the following dictation device handling guidelines will be an eye opener for dictating physicians as we know the importance of transcribed documents and the irreparable damages that a mistake in a transcribed document can make to the life an innocent patient .

The very basic thing is to know your recording equipment; how it works; how to maintain it etc. So before you start up, please read your recorder’s user manual, either the hard copy that come along with the equipment or the soft copy on the manufacturer’s website.
Organize the concerned papers, reports, necessary reference material etc. and keep ready nearby you before starting dictation.
Ensure that you are in an area with no background noise so that your dictation can be heard clearly by the transcriber. Avoid dictating outdoors like seashore, waterfalls or on a stroll with breeze towards the microphone. Extrinsic noise makes it difficult to hear dictation accurately. As well, avoid dictating while driving. It is dangerous and the sound quality too is poor.
Pause a bit before when starting your recorder and pause briefly before stopping recording. This avoids words from being “clipped.”
Dictate with your mouth at the optimum distance recommended by the manufacturer of the recorder for better output. Speak out clearly at a regular pace without letting your voice fade-out at the end of sentences. Do not mumble. Maintain modulation in your voice. Monotony may tend to put transcribers to “sleep.” Be brisk and core to the point with least amount of pauses in the dictation.
Always state and then spell full names of the patients, (their respective medical record number), names of addressees, referring physicians and their proper mailing addresses.
Take care while spelling out as “F” and “S” are heard alike. Give clues for these alphabets, you may spell like “F for France” or “S for South.” Fifty and Sixty are really brainteasers in numbers at the end of transcriber. Do not stress twenty as “twentieth” as it is heard often as “twenty eight.”
Do not forget to include the date of service, date of dictation, date of birth, title of the report, carbon copy (CC) etc.
Spell out unusual words that may represent diseases, drugs or procedures not normally found in the mainstream of your daily work or specialty. Do not try to spell words that you do not know how to spell. If the word is unusual, just say it as clearly as possible as the transcriber can usually confirm the spelling if required.
Always try to include punctuation, especially when starting new paragraphs. Include “open” and “close” quote instructions. Similar is the case with parenthesis. The preferable and proper phrase when dictating is “full stop” rather than “period” at the end of a sentence.
Telephones/cell phones are the other trouble givers. Switch off phones whenever possible or at least keep them in vibrating modes which will be a boon to the transcriber.
Do not play music, shuffle papers, open drawers, rearrange your desk, rip paper off examination tables or make loud sudden noises when dictating.
Please do not mess with the gender of the patient with the dictation starting with a female patient and ending up with a male and vice versa. Make sure to be consistent throughout the particular file. Similarly do not mess switching sides left and right or upper extremities and lower extremities. Else, it is a miserable life on the part of the transcriber.
Use your own set of standard (repetitive) phrases in each of your report. This makes it easier to transcribe your work and lessens the chance of error.
Say “End of Dictation” at the end of your dictation, so the transcriber will know there is no more dictation at the end of the audio file.
Edit errors, if any, by rewinding and erasing them. Do not make errors and then say “strike that” or something like that. Use the “cue and review” feature found on most current recorders to erase your last statement. Erasing your own error also negates any chance of misunderstanding on the part of the transcriber as to what has to be erased from what you dictated.
Service your dictation equipment at least yearly. May be your vacation time is the right time for that. Buy new tapes at least once a year if you use them daily. Discard damaged tapes immediately and only after erasing them.
Do not laugh, yawn, converse in between, scratch, burp, slurp, cough, sneeze, eat, drink, chew gum, clear nasal passages etc., while recording dictation. Sialagogues can be used to keep your saliva flowing.

These dictation guidelines for physicians (for both newly graduating and old doctors) should have enlightened you the probabilities of errors creeping into reports and your involvement required while dictating into the microphone to avoid those errors. If these dictation tips for doctors have really opened your eyes about the seriousness required while dictating, then do not miss to watch AHDI‘s (formerly AAMT) presentation “Dictation Best Practices.” Furthermore, if you have a sense of humor, read Kelly Ratzlaff’s funny list of things to do while dictating!