Okay, I’m assuming most physicians are relatively intelligent, you’re educated at the very least. Here’s a few pointers regarding dictation that seem like common sense to me, but hey, maybe you don’t know:
Slurred speech
Please, can we enunciate a little bit? I don’t want to spend a half-hour hunting for the spelling of “Hashimoto’s fyrovitis” before realizing that you were actually saying “thyroiditis.” Did we have a few cocktails with lunch?
Spelling out words
Hey, if you want to spell out some of the more obscure terms and experimental drugs that might be difficult to find in my books, feel free. I would appreciate it, however, if you’d stop spelling out “aminotransferases.” I knew how to spell it the first time. Also, if you’re going to spell out a word, please spell it right.
Hitting the record button before finishing a personal conversation
I don’t care to hear about your opinions on SUVs, nor do I care to sit and listen to you and your fellow respected physicians make bizarre vroom-vroom sounds.
Bizarre pronunciations
Since when is centimeter pronounced “sonometer?” Is this some kind of weird alternative pronuciation? I’ve heard several doctors do this, and it seriously grates on my nerves. Also, please learn how to pronounce “cervical,” “acetaminophen,” and “hematochezia.”
Accents
Yes, I know you can’t help it if you have an accent, but you can take into consideration that the transcriptionists might have a little difficulty understanding you if you don’t slow down and enunciate.
Consistency
When dictating, please try and remember which drug you prescribed the patient. I don’t want to have to track you down later on after you dictated two entirely different medications and find out which is correct. Also, fellows and supervising physicians, please get your stories straight before you each dictate your notes on that patient. Were those liver tests normal or not?
Skipping around
I have a template to follow. It’s a pain in the ass to have to go back to the history of present illness when we’re in the middle of the physical exam. Also, if you must skip around, please tell me where whatever it is you’re dictating is supposed to go. “Diarrhea - 4-5 bowel movements daily,” that’s obviously not part of the physical exam, did you want that in the history of present illness? In the review of systems? Chief complaint?
Confusing your template categories
Why are you asking me to put the past medical history items in the review of systems? Even I, a lowly transcriptionist, know the difference.
Think before you speak
Do you realize what you’re saying when you say the patient has a pussy exudate? Gee, maybe you should have used “purulent.” Also, I highly doubt the patient was a “32-year-old computer program.”
Long pauses
Yes, you have a button you can hit to pause recording when you need to sit and think for a moment. I don’t like having to sit and stare into space for 3 minutes while you do whatever it is you do.
Repetition
I have a rewind button. If I miss the patient’s ID number, I can go back. You don’t need to say it three times.
Clarity on measurements
Today, I transcribed a note where it sounded like she said the patient was taking ursodeoxycholic acid, 254 tablets a day. Now, if I were the type to just transcribe without paying attention to what’s being said, I would have typed that. Of course, she should have said “250 mg, 4 tablets a day,” actually saying “milligrams,” or at least pausing between “250” and “4.”
Really, I don’t think it would be too difficult to follow these simple guidlines, please, for the sake of my sanity.
Heh…I know, most of them can and do dictate clearly. It’s just that I seemed to have a long string of bad, bad dictations today. (And telling the crappy dictators to clean it up is futile. They always fall back into their bad habits after a brief time.)
On behalf of physicians everywhere, I apologize. In the few clinics that let students dictate, I always take my time and do a good job. Of course, I could type it myself in the time it takes to dictate.
This is a huge running joke at my med school. We claim that there is something that happens at graduation that makes us suddenly start saying “sontimeter” and “neurone”. We’re thinking about doing before and after studies this May.
“Tylenol”
“Bloody stool”
I’m curious–is your template given to you by the physicians you dictate for? Do you always use the standard format (CC, HPI, PMHx, PSHx, ROS, etc.)? Do the docs always (at least claim to) dictate that way?
If you want the doctors to really take notice, type exactly what they say a few times, "ummm…"s and all. Of course, watch the doctor–while an FP will probably take it as a hint to dictate more clearly, a surgeon will want to hire a new transcriptionist who isn’t such a smartass.
Radiologists are the best. Those mofos can talk faster than any humans I’ve ever seen. That and they mumble like crazy so all you hear is
“upright mumble mumble AP border mumble mumble mumble heart shadow mumble mumble pleural mumble midline mumble consistent mumble mumble interstitial pneumonia.”
My friend is going into radiology, and he has been rehearsing the phrases “bilateral subsegmental atelectasis” and “phleboliths in the lower pelvis” and “nonobstructive bowel gas pattern consistent with FOS” so that now he can say them at 400 words per minute. It will save him at least 10 or 15 seconds a day, while taking years of life off of med students and transcriptionists around the world.
Gotta love it. As a med student I had to listen to hours of dictation to get quick results from path and radiology.
Oh, and I will never say sontimeter or neurone, or for that matter umbil-eye-cus.
I work at a very large clinic, with a couple thousand medical secretaries and transcriptionists. We all use a standard template-software thingy (except in Radiology, they use something different down there, and I believe it’s also mostly live dictation, the transcriptionist sits in the room with the doc and transcribes as he/she is reading the films). It has separate boxes for each part of the note, the referral source, chief complaint/reason for visit, history of present illness, current medications, allergies, review of systems, past medical/surgical history, social history, family history, vital signs, physical examination, impression/report/plan, diagnoses, and special instructions.
In general, the doctors stick to the template, and the order in which the categories go. I believe they all go through a little class or something to teach them how the software works and how they should dictate.