Clear, accurate and timely medical records are essential to support patient care. Physicians need to relay precise and accurate data to the other members of the patient’s care team. Dictated reports are usually sent to a third party for transcription. One problem that teams in US based medical transcription companies face is unintelligible reports due to poor dictation. Transcriptionists say that record quality and timeliness depend to a large extent on the quality of the audio recordings they receive from physicians. Let’s take a look at that factors that impact dictation quality and how physicians can improve dictation efficiency.
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Reasons for Poor Dictation Quality
Physicians prefer dictation to taking notes when they are face-to-face with their patients. Dictating frees them to focus on each patient, allowing them to efficiently carry through and conclude each visit, and prepare to see the next patient. Dictation within the exam room reduces the time spent on recording care. However, there are many factors that can detract from dictation quality and make it challenging for medical transcription service providers to deliver accurate notes from the audio sent to them:
- Workload: Busy physicians may dictate on the go or during their busy schedule. This can lead to them dictating too fast and inadvertently missing out critical information when documenting a procedure. Clarity is a major problem with a fast dictation.
- Background noise: Physician dictation doesn’t always take place in a controlled environment. Physicians have a tendency to multitask. They may dictate while eating or chewing gum, or when they are driving or in a crowded room, which can all affect dictation quality. Even if they dictate in a hospital setting, noise created by patients, family members, or medical assistants can affect the dictation recording process.
- Lack of organization: This is another key factor that can impact dictation quality. Not being organized when reporting a case can lead to something important being left out, especially if there are interruptions during the dictation process. In addition to procedural information, dictators who lack consistency can leave out even patient demographic information.
- Speech patterns: Mumbling can happen when clinicians dictate the same procedure several times during the day. In fact, mumbling is one of the most common dictation problems for medical transcriptionists. Speech patterns can also be impacted when the clinician is tired, and result in whispering.
- Heavy accents: Heavy accents may a problem when it comes to medical dictation. Processing the speech of people with accents can be a challenge for both human transcriptionists and speech recognition software.
Dictation accuracy and sound quality are crucial because decisions about treatment and ongoing care are based on information in the chart. Poor dictation habits and bad audio can:
- affect quality of patient care and safety
- result in incomplete coding due to reports with blanks of missing information
- cause delays in care
- lead to delayed reimbursement
- impact transcription accuracy and turnaround time
A reliable medical transcription company will not fill in a report that is incomplete. Instead, they will send it back to the physician for clarification. This causes delays throughout the entire system and significantly increases the time needed to create a complete and accurate report.
Six Best Practices to Improve Clinician Dictation
The correct workflow and practices can significantly reduce the time that clinicians spend on dictation. Here are 6 effective ways to avoid dictation-related problems:
- Physician education: Industry experts say that education is the best way to improve dictation practices (radiologytoday.net). Communicating the importance of high-quality dictation can influence physician by showing them how it supports patient care, billing, and even legally. Beginning a dictation session with proper patient identification is a helpful practice. Informing radiologists about the importance of entering the correct numbers at the beginning of a dictation session will ensure that the correct work type and patient demographics are used. Correct documentation will eliminate the need for clarifications and improve radiology transcription turnaround time.
- Dictating in the presence of the patient: Dictating in front of the patient is recommended. This will not involve any extra time. It will also improve the accuracy of the history and physical as you can ask for clarifications. Patients can get a better understanding of their condition and treatment recommendations. Improving the quality of your records can improved reimbursement, and provide malpractice protection and patient care. Patient-present dictation also increases patient satisfaction as the physician is spending more time with the patient.
- Organize your thoughts: To improve dictating, consider making brief notes or jotting down keywords in advance. This will help you organize your thoughts during dictation and help you include the right information in your narrative.
- Location is important: As we have seen, a noisy dictation environment is a common problem. Even in the hospital, quality is a major concern for dictation done at nurses’ stations where background noise can be overwhelming. As far as possible, dictate in a quiet setting.
- Use speech-to-text: With speech recognition (SR) software, physicians can dictate and immediately review the results of the charting session. The technology offers the best of both worlds – physicians can continue to dictate while avoid typing and quickly document medical history, symptoms, treatment plans, and other observations. Studies suggest that SR can improve overall process efficiency when used for dictation tasks such as reporting radiology or pathology results. Accuracy of machine-generated transcripts can be improved by getting them checked by an experienced medical transcriptionist.
- State numbers and homophones clearly: Numbers and other numerical concepts appear throughout clinical notes and signify the value reported to indicate the function of cells, glands, hormones or organs in the body. When dictating numbers, use the appropriate form. As some digits can be easily confused when dictated, for e.g., 15 and 50, spell them out. This is especially important for medication dosages, where errors can lead to the wrong treatment. Repeat or spell out dosages precisely. Likewise, if not handled properly, homophones or same-sounding words can make a report inaccurate and useless. If you use ‘their’ and ‘there’, spell them out.
Dictation quality is crucial when it comes to documentation quality. Established medical transcription companies guarantee an accuracy level of 99 percent and custom turnaround time with good quality dictation.