Top 10 Tips For Successful Medical Dictation and Transcription
Quality medical dictation affects the accuracy and turnaround time of transcriptions which directly impacts patient care and reimbursements. This article will provide you with the Top 10 tips for successful medical dictation and transcription. Whether you are a small practice or a community health center administrator, the following will be beneficial to you.
Your practice can benefit greatly by improving the precision of your medical dictation skills. Good medical 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 medical 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.
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.
With these practical medical dictation tips, you will help your medical transcriptionist provide you with highest quality service in an expedient manner. High quality patient care, accurate records, accurate billing, lower costs, and fewer legal issues all begin with your clear and precise dictation – a small consideration with very large and far-reaching benefits to your practice and your patients.