Good dictation is the foundation for accurate medical transcription.
A medical dictation is a recording of a healthcare provider speaking about medical history, physical examination findings, and other relevant information about a patient. This dictation gets transcribed into a written report, which becomes part of the patient's medical record.
The quality of medical dictation dictates the transcription quality. Poor quality in medical dictation may invite legal, financial, and patient health repercussions.
This article explores ten ways to improve medical dictation, thereby helping the transcription outcome.
1. Avoid Noisy Environments
Stay away from noisy areas or crowded surroundings while recording. A quiet and secure place helps with patient anonymity and improves audio quality. If outside, avoid areas with loud noises as it interferes with the recording.
2. Speak Clearly
Speak with clarity in a conversational manner. Enunciating words properly avoids mispronunciation which affects the quality of medical dictation.
3. Keep Distance Between Speaker and Microphone
The distance between the speaker and microphone affects the sound quality of a recording. Make sure you speak over the microphone and not directly into it, as it creates distortions and screeches.
An ideal distance of 10 centimeters between the speaker and microphone makes the audio clear.
4. Dictate Right Away
When dictating medical notes, dictate promptly after the patient visit. This way, the information is fresh in the memory and helps with a clear, accurate and complete dictation.
5. Avoid People Talking Over Each Other
People talking over each other can result in missed words and unclear sentences, decreasing the quality of medical dictation. Interruptions are bound to happen. In such cases, pause and continue when the interruption ends.
6. Be Careful of Difficult or Similar-Sounding Words
Take your time while pronouncing difficult words, phrases, and similar-sounding words. Be mindful of the drug name and the name of the referring physician. Spelling out the word is a good practice to avoid confusion.
7. Clearly State Numericals and Measuring Units
Pay attention while stating numbers. Mention each number separately. For example, 'Six Hundred and Fifty Four' or '6-0-5-4.' When mentioning measuring units, be extra cautious.
A ‘milligram’ versus a ‘microgram’ can hamper patient safety and possible litigation for the physician.
8. Learn How to Use Your Device
Before you start recording, get to know your device. Be familiar with the record, pause, play, stop, delete and overwrite buttons. A test recording is useful for this case.
9. Wait a Second After Pressing the Record Button
Don’t speak immediately after you press the ‘record’ button. You risk cutting off words when you do that. After you press the ‘record’ button, wait for a few seconds and then start with the dictation.
10. Don’t Overlap Words Together
Speaking quickly can risk words running words over. This is especially true for small words. There’s a big difference between ‘The patient has no history of hypertension’ and ‘The patient has a history of hypertension.’
Therefore, take your time and speak slowly and clearly when dictating medical reports.
Accuracy is More Important Than Speed
Producing a good quality medical dictation might need some practice and take some time. A few mindful hacks can ensure your dictation is clear and understandable to the transcriber. Always aim to better accuracy than trying to achieve a higher speech.
Improving your dictation practice saves time and avoids frustration for both physician and transcriber, and saves you from potential errors.