A medical transcriptionist (MT) has a lot of difficulties in her day-to-day lives. Every MT starts her day with a prayer: “Let all the work end up perfectly and no issues should arise.” However, her fate is purely not dependent on her effort alone. The responsibility rather rests with the dictating physician. MTs want to convey the dictation device handling guide given below to the doctors. However, most of the times they are unlucky.
I am assuming the role of their angel here. I hope that this dictation device handling guide will be an eye-opener for a doctor like you. We know the importance of transcribed documents. A mistake in a transcribed document can make irreparable damages to the life of an innocent patient. Let’s try to avert those situations. So please read these guidelines below.
Dictation device handling guide for physicians
- The very basic thing is to know about your recording equipment. Beforehand, please know 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 comes along with the equipment or the soft copy on the manufacturer’s website.
- Organize the concerned papers, reports, necessary reference material, etc. Keep them ready near you before starting the dictation.
- Ensure that you are in an area with no background noise. This ensures that the MT hears your dictation clearly. Avoid dictating outdoors like seashore, waterfalls or on a stroll with breeze towards the microphone. Extrinsic noise makes it difficult to hear the dictation accurately. As well, avoid dictating while driving. It is dangerous, and the sound quality too is poor.
- Pause a bit before starting your dictation. Pause briefly before stopping recording as well. This avoids the words from being “clipped.”
- For better output, dictate with your mouth at the optimum distance recommended by the manufacturer. 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 tends to put MTs to “sleep.” Be brisk and core to the point with the least amount of pauses in the dictation.
- Always state and then spell the 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. “F” and “S” are heard alike. Give clues for these alphabets. You may spell “F for France” or “S for South.” Fifty and Sixty are really brainteasers in numbers at the end of the MT. Do not stress twenty as “twentieth.” It is heard as “twenty-eight.”
- Do not forget to include the date of service, date of dictation, date of birth, the title of the report, carbon copy (CC), etc.
- Spell out unusual words that 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 MT can usually confirm the spelling if required.
- Always try to include punctuation, especially when starting new paragraphs. Include “open” and “close” quote instructions. Similarly the parenthesis. The preferable and proper phrase when dictating is “full stop” rather than “period” at the end of a sentence.
- Telephones and cell phones are the other trouble givers. Switch off phones whenever possible. At least keep them in vibrating modes which will be a boon to the MT.
- Do not play music, shuffle papers, open drawers, rearrange your desk, rip the 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 reports. 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 MT 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 MT as to what has to be erased from what you dictated.
- Service your dictation equipment at least yearly. 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.
This dictation device handling guide for physicians (for both newly graduating and the old doctors) should have enlightened you the probabilities of errors creeping into the reports and your involvement required while dictating into the microphone to avoid those errors. If these dictation tips for doctors have opened your eyes about the seriousness required while dictating and if you have a sense of humor, read Kelly Ratzlaff’s funny list of things to do while dictating!
A must-read article for dictators.