WaveSense Posted March 27, 2012 Report Share Posted March 27, 2012 So question to all the residents and maybe some cc4s, how did u learn how to dictate? Is there a general pattern thats out there for what you say? It seems like I can present a history/physical, but the dictation is so much different... Any good websites? Link to comment Share on other sites More sharing options...
Lactic Folly Posted March 27, 2012 Report Share Posted March 27, 2012 Nuts and bolts of working with human transcriptionists: http://www.medword.com/dictation.html As for the actual content and format of notes, most of us just learned by looking at others' transcribed reports. Link to comment Share on other sites More sharing options...
tooty Posted March 27, 2012 Report Share Posted March 27, 2012 DO NOT Burp, slurp, cough, sneeze, eat, drink, chew gum, clear nasal passages, "pass wind," urinate or defecate while recording dictation. (Yes, all the aforementioned have been done by physicians while dictating, and yes, you can hear it, and yes it is disgusting - not to mention just plain rude.) :eek: Link to comment Share on other sites More sharing options...
torontohopeful Posted December 2, 2012 Report Share Posted December 2, 2012 :eek: OH MY GOD THAT IS SO GROSS. Link to comment Share on other sites More sharing options...
futureGP Posted December 2, 2012 Report Share Posted December 2, 2012 i actually think i type faster than I speak so.. hopefully dictating isn't necessary Link to comment Share on other sites More sharing options...
bloh Posted December 2, 2012 Report Share Posted December 2, 2012 It depends on what kind of dictation report and they all differ slightly depending on specialties. My only advice is to offer to do dictations whenever possible. It's the only way to get better at it. Dictations used to provoke such intense anxiety but now I'm pretty comfortable (and quick) in doing them. Link to comment Share on other sites More sharing options...
Renin Posted December 2, 2012 Report Share Posted December 2, 2012 Just pretend you're talking to someone, and they're going to take over care of this patient, and you're telling them about them. My dictations still kinda stink, but they're a lot better when I started! Link to comment Share on other sites More sharing options...
rmorelan Posted December 2, 2012 Report Share Posted December 2, 2012 i actually think i type faster than I speak so.. hopefully dictating isn't necessary May not have a choice - you don't always have access to the EMR that lets you dump in text. It is just a skill that takes practise....and more practise..... Link to comment Share on other sites More sharing options...
rmorelan Posted December 2, 2012 Report Share Posted December 2, 2012 OH MY GOD THAT IS SO GROSS. Yes, yes it is. Ever since those blue took headsets became popular I have seen some doctors using them for dictation - the system is on speed dial for dictation access. It is amazing to watch someone dictate WHILE writing orders. There must be so much flying on autopilot there Link to comment Share on other sites More sharing options...
jerkoutnow2 Posted December 2, 2012 Report Share Posted December 2, 2012 Just pretend you're talking to someone, and they're going to take over care of this patient, and you're telling them about them. My dictations still kinda stink, but they're a lot better when I started! so did you have to hire a transcriptioner as a resident? or does the hospital provide you one? so do transcriptioners basically write your chart for you? :s kinda confused as to how it works Link to comment Share on other sites More sharing options...
rmorelan Posted December 2, 2012 Report Share Posted December 2, 2012 so did you have to hire a transcriptioner as a resident? or does the hospital provide you one? so do transcriptioners basically write your chart for you? :s kinda confused as to how it works No the hospital has them on staff - it is for sending letters basically to other teams/doctors - your report of the procedure or clinic visit. The transcription service writes the letter from your little speech and then faxes/mails the report to the other referring doctors or others involved in the care. It also is uploaded to the EMR in most cases so you can view it from any computer in the hospital network. Chart writing is more for day to day progress updates etc. That is still hand written. Link to comment Share on other sites More sharing options...
Renin Posted December 2, 2012 Report Share Posted December 2, 2012 so did you have to hire a transcriptioner as a resident? or does the hospital provide you one? so do transcriptioners basically write your chart for you? :s kinda confused as to how it works There is a transcription service - I wouldn't hire one if I had to; I'd just type things out. They write out things for you like discharge summaries, admission reports, consultant notes, etc. Usually these are things that need to be stored in an electrical medical records or be sent to another physician(s). I don't do daily dictations. Some services, however, dictate progress notes. Link to comment Share on other sites More sharing options...
leviathan Posted December 2, 2012 Report Share Posted December 2, 2012 Most of the pocket med books have templates for dictation that you can copy. Also it does vary depending on the hospital for what kind of format people like for admissions vs consults vs discharges etc. Link to comment Share on other sites More sharing options...
NLengr Posted December 2, 2012 Report Share Posted December 2, 2012 May not have a choice - you don't always have access to the EMR that lets you dump in text. It is just a skill that takes practise....and more practise..... Really? I can bang out a full length high quality consult note in less than 5 minutes no problem by dictating. A follow up note? Less than a minute. If I write/type/voice recognition out the same info it takes 2-3x as long. And I'm not a slow typerby any means. Once you get good at dictating, it's easily the fastest way. Also, as a Newf, I speak pretty damned fast, so that helps even more. Link to comment Share on other sites More sharing options...
rmorelan Posted December 2, 2012 Report Share Posted December 2, 2012 Really? I can bang out a full length high quality consult note in less than 5 minutes no problem by dictating. A follow up note? Less than a minute. If I write/type/voice recognition out the same info it takes 2-3x as long. And I'm not a slow typerby any means. Once you get good at dictating, it's easily the fastest way. Also, as a Newf, I speak pretty damned fast, so that helps even more. ? Oh I didn't say once you got good at it you weren't blazing through them Just that initially a lot of people struggle with the system. Link to comment Share on other sites More sharing options...
1234 Posted December 2, 2012 Report Share Posted December 2, 2012 No one, once proficient in dictating, can type out notes faster the dictating them. You don't need to practice - its about having a mental template to ensure you cover everything and sound organized. For consultations, mine is: ID: Referring for: Referring Service: Allergies PMH Meds Social Hx History/Medical Course: P/E: Investigations: BW - Imaging - Ancillary - Impression: Plan: CLINIC NOTES: ID: Diagnosis: Plan: S: O: A: P: Link to comment Share on other sites More sharing options...
NLengr Posted December 2, 2012 Report Share Posted December 2, 2012 No one, once proficient in dictating, can type out notes faster the dictating them. You don't need to practice - its about having a mental template to ensure you cover everything and sound organized. For consultations, mine is: ID: Referring for: Referring Service: Allergies PMH Meds Social Hx History/Medical Course: P/E: Investigations: BW - Imaging - Ancillary - Impression: Plan: CLINIC NOTES: ID: Diagnosis: Plan: S: O: A: P: I agree. Good dictation is all about having a set format, with set phrasing, you use all the time. People struggle with dictation when they try to make unique notes every time. Link to comment Share on other sites More sharing options...
tooty Posted December 2, 2012 Report Share Posted December 2, 2012 I would love a good dictation app for my phone. all the ones i've tried suck. Link to comment Share on other sites More sharing options...
rmorelan Posted December 2, 2012 Report Share Posted December 2, 2012 Ha - it took me practise just to think in that mental template and not lose track of important data Templates are key though - otherwise you are just blabbering No one, once proficient in dictating, can type out notes faster the dictating them. You don't need to practice - its about having a mental template to ensure you cover everything and sound organized. For consultations, mine is: ID: Referring for: Referring Service: Allergies PMH Meds Social Hx History/Medical Course: P/E: Investigations: BW - Imaging - Ancillary - Impression: Plan: CLINIC NOTES: ID: Diagnosis: Plan: S: O: A: P: Link to comment Share on other sites More sharing options...
NLengr Posted December 2, 2012 Report Share Posted December 2, 2012 I would love a good dictation app for my phone. all the ones i've tried suck. Don't hold your breath. Dragon is the leader in the field and it still sucks. I have it on my phone but quickly quit using it. Link to comment Share on other sites More sharing options...
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