Dictating is an inseparable part of a physician’s functions. In fact, accuracy and timeliness in medical transcription depends on clear, error-free dictation by the healthcare provider. Even with electronic health records, medical transcription services have not lost its significance with industry experts recommending a blended approach.
According the Medscape Malpractice Report 2015, poor documentation of patient instructions and education was listed as one of the main reasons why specialists in general surgery get sued. Good dictation practices are important to avoid transcribing errors and ensure quality clinical documentation. Transcribing mistakes can have adverse consequences on patient care, result in legal issues, impact coding and billing, and ultimately affect practice revenue.
Dictation Challenges that Medical Transcriptionists Face
Physician workload and their tendency to multitask affect the quality of the dictation significantly. Some physicians dictate on their speakerphones while in a car and some in rooms with a lot or people talking, which badly affects clarity of the recording. One of the problems of poor dictators is lack of a consistent format. Patient demographic information is not entered and even if it is, the information is incomplete. Accents, background noise, and speech patterns all affect the quality of physician dictation.
Tips to Ensure Quality Dictation
The following steps can help physicians get the best outcome from their medical transcription company:
- If you use a digital recorder, learn how to use it properly.
- Speak clearly and in a conversational tone.
- As far as possible, try to record the dictation in a quiet place.
- Spell out unfamiliar medical words, terms and names of new drugs or treatments.
- Have necessary documents and reports in place before starting the dictation.
- Use punctuation at the beginning and end of paragraphs and sentences.
- Provide adequate patient identification at the beginning of the dictation. Patient details such as full name and address, patient record number, date and time of the interaction, and subject matter should be clearly specified. Among other things, missing information in a record will delay billing and reimbursement.
- Consistency can help while dictating similar reports. This will make the file easier to transcribe and lower the chances of errors.
- Do not use slang or abbreviations unless they are commonly used in the medical field.
- If you happen to make an error, delete it and rerecord the term or phrase.
- Digits should be clearly specified for patient safety reasons. Incorrect dosages in the patient chart could be disastrous. For instance, the numbers 13 and 30 could be confused and it is best to spell out similar sounding numbers and homonyms for the sake of clarity.
Poor sound quality and dictation have an immediate impact on timeliness. Medical transcriptionists may have to spend several hours on a poorly dictated report. As dictation is not part of medical training, physicians need to review and hone their maybe dictation skills. Going by the above tips will promote timely and accurate medical transcription.