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The XY Files in an MT World

MT Service Publishes Dictation Tips for Physicians

Published June 25, 2009 1:36 PM by Jay Vance
In a June 25, 2009 press release, medical transcription service company MxSecure, Inc. has announced the release of a white paper entitled, "Top 10 Tips For Successful Dictation" for physicians. From the document:

The quality of your dictation affects the accuracy and turnaround time of your transcriptions which directly impacts patient care and reimbursements. Your practice can benefit greatly by improving the precision of your dictation skills. Good dictation will bring you savings, as well: poor dictation consumes time and labor, increasing overall documentation costs. Finally, quality dictation can even help you legally: fewer transcription mistakes caused by poor dictation equate to fewer errors in patient care.

By incorporating the following top 10 tips for successful dictation, you can accelerate the time it takes medical transcriptionists to learn the style of your dictation, as well as improve their accuracy - all the better for you to run an efficient and high quality medical practice. A win-win for all.

The tips include:

1. At the start of your dictation, gather any papers, reports that you might need for your reference.

2. Dictate as if you are speaking to the patient in an exam room, speaking clearly so the Medical Transcriptionist will understand you without error.

3. Speak at a steady pace and not too loudly or softly. Keeping the recorder approximately 8-10 inches from your mouth will help improve clarity. Always move your face away from the recorder to sneeze or cough.

4. Minimize noises including the TV or radio, eating, drinking, chewing gum, shuffling papers, opening drawers, rearranging your desk or making loud noises as they can be very distracting to the medical transcriptionists. Likewise, do not dictate in a crowded room. The background noise is distracting and you may be sharing protected health information inadvertently.

5. Avoid multitasking while performing dictations. Use the pause button if you would like to take a sip of water or sort out documents. Do not dictate while driving. The sound quality is usually poor, not to mention that it is dangerous.

6. Identify yourself and state what type of report you will be dictating. Detail any special instructions at the beginning of the dictation. State, and then spell full details of information such as the patient's full name and proper mailing address on letters.

7. During the dictation be as specific as you can with spelling, phrasing, formatting and ‘normals'. Spell the names of patients that you think the Medical Transcriptionist may not understand (i.e. ‘Amy' spelled instead as ‘Aimee'), as well as local names or cities. Clearly spell words that may not be commonly used in the medical field, including new pharmaceuticals or treatments and unusual words representing diseases, drugs, or procedures not normally found in the mainstream of your daily work or specialty. Use the same phrases in each of your report types and follow the same order of headings whenever possible. Furthermore, be specific when inserting "normals". If you need to change any part of the normal, please indicate exactly what information the medical transcriptionist should delete and where to insert changes.

8. Include punctuation, especially when starting new paragraphs, and include "open" and "close" quotation mark instructions.

9. Avoid using a lot of "ahhhs," "ums," "ers" and "uhhhs." They can be confused for the letter "a".

10. While cellular phones are convenient, the sound quality is usually not ideal. Land lines will give the medical transcriptionist a better quality recording.

I must say it's refreshing to see a transcription company publicly acknowledging that the quality of dictation, which is the dictator's responsibility, has a direct impact on the accuracy, timeliness, and reimbursability of finished transcripts. Working MTs have long been pressured to produce accurate work on short turnaround time, but the fact is the quality of the original dictation has a lot to do with how well MTs can do their jobs. Whether or not this white paper will have any discernible effect remains to be seen, but I definitely give MxSecure kudos for making the effort.

Are there any other tips you'd like to give dictators if you could? Please feel free to comment.

3 comments

I would ask that doctors spell the names of any other doctors the patient sees, as the transcriptionist may not be in the area where the doctor's practice is and will have to take time to look up local doctors' names on the internet or a phone book if she/he has one for that area. The doctor should also spell the names of any doctors who will be sent copies of the report.

Carolyn, , medical transcriptionist Accutype June 28, 2009 12:05 PM
Charlottesville VA

While dictating try and use a linear approach, avoid jumping back and forth between headings and subheadings.

Laurana Thomas, Medical Transcriptionist June 26, 2009 4:53 PM
CA

Great! Close resemblance to those that I charted out here way back in 2007:  http://mtherald.com/tips-for-dictating-physicians/

Raj June 26, 2009 1:50 AM

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About this Blog


    Jay Vance, CMT
    Occupation: Medical Transcription Industry Consultant
    Setting: Yuma, AZ
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