In this era of digitalization and automation, conversion of audio recordings into data files is common in various transcription fields like medical, general, business, legal, academic, insurance, media, etc. Among all these, the demand for medical transcription services has expanded considerably worldwide because of the ever increasing work requirement. Physicians have been dictating their patient data for years, but transcriptionists often find it difficult to understand the dictated material entirely. This is because the quality of dictation is poor with many factors contributing to the sub-standard dictation quality.
- The first thing transcriptionists struggle with is the poor audio quality. This may be due to low volume or other disturbances that occurred while recording the audio. The audio quality may vary on some recording devices while traveling, eating, or dictating in public places.
- Poor dictation is not always about accents, background noise, speech patterns or faulty devices. Various habits contribute to poor dictation, such as mumbling or gurgling sounds, which can severely affect quality of the audio.
- When more physicians are involved in the care of a patient, dictation quality may become poor especially when all of them speak together.
- .Some physicians may not even provide patient demographic information and are very inconsistent regarding the format they use. Such reports could be very confusing for the transcriptionist.
- The tendency to multitask also can detract from dictation quality.
- Fast dictation and poor articulation are considered the most frequent causes of transcription errors, as an AHDI (Association for Healthcare Documentation Integrity) study points out.
- Physicians may also misuse medical terms.
The quality of patient care and safety are the primary concerns that arise from poor dictation. Incorrect dosages could be disastrous because treatment decisions are based on information mentioned in the chart. When it comes to difficult dictators, the medical report will be on hold within the transcription team to complete the report. That obviously holds up the patient care and timely physician reimbursement. Medical transcription companies are paid on production basis. If they have to struggle through reports of difficult dictators, it will slow down their overall productivity and thus negatively impact their income potential.
How to Ensure Better Quality Dictation
Physicians need to be trained or given certain instructions before dictating a medical record. They should collect their thoughts before they start dictation or learn how to use the pause feature available in the devices instead of saying ‘Um’, ‘Let me think’, etc. Transcriptionists also need clear voice quality for digits that are easily confused (e.g. 15 and 50). Here are some other best dictation practices to follow:
- Physicians must familiarize themselves with the recording equipment they plan to use and do some practice sessions.
- Ensure that the background is quiet so that they are not distracted or disturbed during the dictation.
- Before starting to dictate, make sure that all papers and reports are at hand.
- Speak clearly and at an even pace. It is important that doctors do not eat or chew gum when dictating.
- The physician should identify himself/herself at the beginning of their dictation. Also mention the type of report and the date to be mentioned in the report.
- Spell out full details such as addresses, full name, file numbers, reference numbers, subject matter and patient record number.
- When dictating, ensure that words spoken do not get cut off.
- Spell unusual diseases, drugs with complex names, and procedures not normally performed in the physician’s daily work or specialty.
- Mention all punctuation clearly.
- Ensure that the dictation equipment is serviced regularly.
Doctors need to be held accountable for the quality of the dictation they provide, just as they are for all other facets of the patient’s care. Medical transcriptionists are not expecting physicians to speak in slow motion, spell every word, or exaggerate enunciations. However,because of patient safety concerns, they wish the dictation should be in a clear and concise manner. Depending on the organization, incentives and penalties may also be tools to improve dictation practices.