Poor Dictation Practices – Challenges and Solutions

Challenges and SolutionsPoor dictation is a huge challenge for medical transcription services making the transcriptionist’s job quite difficult when they have to spend considerable time trying to figure out what the physicians are saying. Bad recordings contain too many inaudible terms and it is extremely difficult to get good transcripts from such recordings.

Many habits contribute to poor dictation. Even physicians, who normally speak clearly, occasionally fall victim to one or more of them. Tight schedules and heavy workloads of providers can lead to a decline in the quality of dictation. Physicians eat and mumble or sometimes they become tired and yawn while talking. They sometimes speak on the speakerphone while driving. The tendency to multitask also can detract from dictation quality. These are the main reasons that can result in poor quality dictation. Foreign accents and heavy accents are also significant hurdles for transcriptionists.

However, poor dictation is not just because of background noise, speech patterns or accents. The quality and timeliness of the final transcripts also depend a lot on the efficient transmitting of accurate and complete information. Many physicians are inconsistent in their dictation – they may leave out important data such as patient demographic information among others.

Serious Impact of Poor Dictation Practices

The quality of patient care and safety are very important and these are affected by poor dictation. Accuracy and timeliness are also affected.

  • It is on the basis of the information provided in the transcripts that treatment decisions are made. Incorrect dosages or inappropriate treatment can have serious negative consequences. So reliable medical transcription companies do not prefer to guess if some part of the dictation is unclear.
  • Usually, an incorrect or incomplete recording is sent to a lead within the transcription team who will attempt to understand what is being said and provide a correct transcript. In some cases, the incomplete data may have to be rechecked by three or four leads to arrive at a clear understanding and accurate transcript.
  • Poor recordings therefore result in considerable time delay, which in turn affects turnaround time when they have to be sent to leads and editors for further clarification. If the transcription team fails to understand the recording clearly, it will be sent back to someone in the client organization for further action.

Another issue that is likely to arise when physicians are poor dictators is delayed reimbursement. When there is confusing or missing information in a medical record, it ends up in reports with many blank spaces. In such instances, the report has to be sent back to the concerned physician for clarification. This will cause delay in submitting the bill and obtaining reimbursement.

So What’s the Solution?

  • In an organization, dictation practices can be improved by utilizing incentives and penalties. Poor dictators can be identified and educated on the necessity of clear dictation.
  • The administration must constantly emphasize the importance of good dictation and its impact on patient care, improved reimbursement and minimized liability.
  • It is also a good idea to encourage physicians who are good dictators to better their skills if they can improve further.

The partnering medical transcription company can provide useful tips to their clients as regards how to create good quality recordings. They can emphasize how the quality of the audio file will affect the ease of transcription, quality of the transcript and the transcription cost.

How Physicians Can Ensure Good Dictation

The physician should be attentive and consistently lucid, use proper grammar and be considerate of the person listening to their dictation. Medical transcriptionists do not expect physicians to speak slowly but avoiding other activities such as eating while dictating is advisable for a clear and crisp recording. Among the best practices for clear dictation is starting the session with proper patient identification. This will help prevent confusion. Saying numbers clearly, especially when it comes to dosages is essential for patient safety reasons. Numbers that are easily confused such as 15 and 50 are best spelled out. Dictators should organize their work into structured format to eliminate time-consuming practices.They should also make it a point to organize their thoughts before starting the dictation so that there will be continuity and clarity, which will help the medical transcription team to ensure accurate medical transcripts.