Accurate clinical documentation is critical to health care quality and safety. The quality and accuracy of medical transcripts are also crucial, because treatment decisions are based on the information in the chart.Error-free transcripts can be achieved only with clear medical dictation. With poor dictation and recording, even a professional medical transcription company will find it difficult to transcribe the records and thus fail to meet the turnaround time. Documentation errors that have an effect on clinically relevant data may pose risks to patient safety.
Poor dictation habits can severely affect
- the quality of patient care
- timely reimbursement
- medical transcription provider’s turnaround time
Often physicians may not pay due attention regarding the format they use, patient information, accents, background noise, and speech patterns. Such a poorly dictated report requires more attention and time from transcribers as well as multiple levels of review.
Best dictation practices to follow
While recording an audio file that needs to be transcribed, you must keep in mind these best practices.
Choose a calm and quiet environment
Doctors are often interrupted in their consultation room and background noise can be overwhelming.For transcriptionists, it may be challenging to deliver error-free transcripts especially when the dictation contains incomprehensible accents, mumbling, rapid speech and disturbing noises, which prevent them from meeting the expected accuracy level.You can even consider dictating in an outdoor location, while avoiding noisy areas such as that with traffic noises or windy areas which can compromise the audio quality. Hospitals should understand that high-quality dictation is for their own good too. Recording in incorrect formats can also impact the timely return of reports.
You should avoid speaking with your team members during the recording and also avoid other noises such as the ringing of mobile phones. In case of any distraction, make sure to pause the recording on your device.
Watch the dictation speed and volume
Often, physicians may be busy with their schedules and rush through the dictation process, resulting in reduced clarity.Dictating at an even pace helps the transcriptionist hear every tone of a vowel or consonant in a word.Volume issues are also a concern. If the volume of the recorded file is low or if the physician whispers, transcriptionists will be stuck. They can’t get what they can’t hear.Dictators have to speak loudly and clearly.
If you are new to the recording equipment, try test dictations and send the final copy. Send only encrypted audio files for transmission to your transcription provider.
Data organization matters
Another factor that leads to poor dictation is the lack of organization. If a medical case is reported unorganized and if they are interrupted, there are chances for doctors to leave out key points.For instance, if the dictator is explaining a surgical procedure and failed to mention closing the incision, transcribers too will not report this, leading to further consequences. Physicians should organize the data before dictating, by identifying details of referring physician information – address and/or fax number, the patient’s demographic details as well as how to send the report (mail or fax) and to whom. Start each dictation with your name.
Provide clear details
Make sure to include the patient’s full name, proper mailing address; file numbers; reference numbers; patient record number; and subject matter. Also, give clear instructions such as a starting a new paragraph as well as indicating punctuations, open or closed quotes and parenthesis.
Use abbreviations, only if their expanded form is reported at least once in the recording. Never abbreviate names of medications. Dosage instructions should also be dictated consistently to avoid any errors in transcript.
Plan a clear dictation process
With a clear dictation system and best practices prepared, doctors joining the facility can just go through and follow them to ensure quality dictations.The hospital’s transcription department or the medical transcription company the hospital has partnered with needs to maintain a log that records documentation problems, which would enable them to track any physician issues.Transcription providers can also rank their physicians in terms of correction effort, which provides another level of measuring their success as dictators.Physicians can ask for feedback on their dictations from the transcriptionist, which would help them improve.
Hire skilled transcriptionists
While poor dictation makes quality healthcare documentation a difficult job, practices must make sure that their transcriptionists have sound knowledge of basic to advanced medical terminology related to diverse areas including anatomy and physiology, disease process, and laboratory values and procedures.While dictating too hard medical terminologies, it is better for physicians to just spell out the word.It is recommended to consider medical transcription services provided by an experienced company, as an established firm will meet better accuracy level.
Many practices are now relying on speech recognition tools to transcribe their recordings, which help to improve EHR clinical documentation accuracy and boost patient safety. Even if such software can convert your words into text, quality checks need to be done to ensure accuracy. A study published in JAMA Network Open that analyzed how accurate dictated clinical documents created by speech recognition software are, has observed an error rate of more than 7% in speech recognition – generated clinical documents, which demonstrates the importance of manual editing and review.