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IMPORTANT TECHNIQUES TO USE DURING MEDICAL DICTATION

March 25, 2019

WHAT IS MEDICAL DICTATION:-

The sole purpose of the working of doctors is to save lives. They always try their best to improve the wellbeing and health of their patients.
    For providing effective care, a physician always requires the exact information. He really needs to know exactly what is going on with the patient. Sometimes it becomes very difficult to determine. It often takes so many appointments, tests, scans, diagnoses before a conclusion can be reached.
   The documentation is the key that draws together all the strands of information. Each and every interaction is recorded in detail so as to draw a complete picture of the conclusions and the outcomes.

THE PROCESS OF DICTATION WORKS IN THE HEALTHCARE INDUSTRY:
If a new see the whole process of the dictation work, it looks very simple. The core process of dictation is:- A physician or a healthcare professional dictates into a device, that audio is sent to a transcriptionist who then types it into a document. The clinician can then review the document, sign it and allow or authorize it to be sent.
A number of dictation workflows call the audio creator the author and the transcriptionist a typist.
All the attempts of formatting, editing and typing are taken away from the physicians. The doctor only needs to produce the initial dictation file.

REQUIREMENTS FOR THE MEDICAL DICTATION:-
There are the basic 3 levels that the medical dictation requires. First an author, second a typist and finally a process of connecting the audio produced by the physician with the typist.

Generally, the authors in the medical industry are clinicians and doctors. Being fond of dictation is not always easy. One needs to speak clearly and eliminate the low sounds as much as possible that is used in the general conversation (like Umm, err, hmmm mm ). But dictation is many times faster than writing the document by hand.
Typists are the backbone of the dictation system. In the medical setting a dictated audio file is tough to use and can’t say to other users at a glance what they need to know. Typists, like clinicians, require some training and experience to perform according to the requirements of the healthcare industry. Typists need the familiarisation with the dictation files, with the patterns of speech and with some of the nuance that each and every clinician might have the way they work.
Finally, a dictation system is needed. Something that can collect the dictation files from the authors and connect typists to perform the transcription. In recent years it has often been performed with the audiotapes. Nowadays digital dictation is very popular. The digital dictation system includes an input device like a dictaphone or mobile phone and software to manage the files. Depending upon the needs for data security the system may need a server solution.

There are so many latest techniques for medical dictation to use. Let me talk in brief. Have you ever faced such kind of problems when you are trying to record a patient’s data with maximum quality and clarity but you are unable to get the desired result? As a doctor or medical faculty, you better know that the clarity of dictation is very important. Especially it greatly contributes to the accuracy of the transcribed medical record. If the recording will not be clear, even a certified Medical Transcription Companies will find it inconvenient to convert the records and might end up wasting too much time and effort. Also yet, there is no assurance that the records will be accurate. And we better know the quality rating of the most transcription companies depend upon the sound quality of the audio files.

FEW MEDICAL DICTATION TIPS TO USE WHILE RECORDING AN AUDIO FILE FOR MEDICAL TRANSCRIPTION:

THE NOISES OF SURROUNDINGS:
Always try to choose an area with less surrounding noise, especially microphones catch noises very easily. Dictating in a quiet and secure surrounding will definitely improve the result and also maintain the patient confidential. It is the best practice for Medical Dictation not to record in the areas having surrounding noises and distractions like – people talking, ringing cell phones, music sounds, vacuum, other speakers and beepers, etc. Even the voice of air conditioning can increase the unwanted sound in the surrounding. Sometimes, you have no option but to dictate in the outdoor location, then you should try to avoid such areas like a lot of traffic noises, very windy type of areas. These factors can compromise audio quality.

TRY TO SPEAK CLEARLY IN THE MICROPHONE:
The conversational tone should be at a normal rate. So, the transcriptionists can understand the dictation easily. who needs to provide the quality records. Also depending upon the microphones. The recorder needs to be placed about 3/4″ from the mouth in an upright level position so that sound hits over the top of the microphone and not directly into it. If you are using a smartphone or tablet then it’s essential to know where the mic is to make sure that you are not covering it with your hand while recording. Generally, microphones over built-in microphones provide better quality.

SPEAK ONLY ONCE AT A TIME:
Brief your team members about the digital audio recording and if they too are going to participate in the recording. For better quality request them to speak one person at one time in a clear voice and slow rate of speech. You may also tell him to avoid talking to one another during the recording.

QUALITY ASSURANCE:
Before sending the recording to the transcriptionist, it will be the best to first conduct a test of your own recording. Talk a few sentences and then check the sound level and the quality of the recording. It will give you an overall idea of quality and your speech. It will also give you an idea about what you need to include and what you need to remove.

BE AWARE OF DIFFICULT TERMINOLOGY:
The medical terminologies can be difficult for the transcriptionists to decipher at times. You should make a note of unusual or difficult terms, similar sounding words and the names of referring physicians. If you think there can be a chance of confusion then it’s better to spell it out. While most certified dictation services hire competent transcriptionists who generally do double check the spelling. Sometimes when the words are not able to transcribe they end up leaving the blank spaces in the transcript.

Overall it’s better to use well-certified transcriptionists who can easily understand a wide spectrum of accents and dictations to a certain degree. To get to know whether your accent will be understood by the transcriptionist, you should first submit a sample dictation as a test. Physicians are highly concerned about the accuracy of transcribed reports. Especially as mistakes can cause considerably severe legal and financial impact.   As it depends upon the dictation. You should try as much as possible to record a file that has no background noise.

FEEDBACK:
The feedback is also a major part to improve the quality of your work. Timely feedback is very important when working with new transcriptionists, and continues to be important if an issue arises. Changes due to author error generally incur a charge.


SUMMARY:

Key for Better Services- Good Dictation & Work Habits

Instead of using a keyboard and mouse using speech to document encounters are more natural. In a recent NIH-supported research study by ZyDoc, Clinical dictation has been shown to be an average of 2.5 times faster than typing. Someone should learn n dictation where speaking is a more natural modality, good speech habits.

Achieving excellent transcription also demands attention to workflow details such as providing completed information and correct information. Getting the right information saves time and frustration for both the author and the transcriptionist, and reduces the probability of the errors.

NOTE ABOUT SPEECH RECOGNITION:

In the early stage “Speech Recognition Technology” emerged as the proposed solution for saving the clinical documentation time. Front-end SRT allows an author to dictate, also monitor the text on the screen with minimal lag time and perform immediate edits. Back-end SRT reviews correct, or in some cases, re-types the report after completion of a dictation session for subsequent routing to a transcriptionist or editor.

By: Anna williams Category: blog

2 thoughts on “IMPORTANT TECHNIQUES TO USE DURING MEDICAL DICTATION”

  1. Speaking clearly and at moderate speed is very important. I’ve done some transcription work myself (not for medical purposes though) and sometimes the person talking (without realizing) reduce they voice and speak fast, and hence all we hear are muffled notes. Since this is Medical Transcription, extra care has to be definitely for this. Useful tips. Overall, nice article Anna.

  2. Thanks Steven Kenneth. I’m happy to share it.

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