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The following points are simple,
basic guidelines to follow when dictating medical reports. If you
follow these recommendations, transcriptionists will be more likely
to produce transcription of your dictation in an accurate and timely
fashion.
Dictation
Do's
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DO Learn about your recording
equipment; how it works; how to maintain it. You can usually
find your machine's user's guide on the manufacturer's web site.
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DO Assemble any papers,
reports, before you start dictating.
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DO Make sure you are in a
quiet area so your dictation can be heard clearly by the
transcriptionist.
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DO Identify yourself at the
beginning of your dictation and state what dictation you are
doing, i.e., what type of reports and the date you want
reflected in the reports. (The day of patient examination, the
date of your dictation, or the date the transcriptionist is
actually transcribing the work.)
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DO Say “Hello” to the
transcriptionist who will be transcribing your digital audio
file. It is surprising how many people who dictate fail to
acknowledge the person who will be transcribing their dictation.
Even if your digital audio file is sent to a “transcription
pool” and you therefore do not know who will be transcribing it,
a short, friendly word at the beginning of each file can
sometimes lift the spirits of whomever is transcribing your
work. Many transcriptionists enjoy doing work more for someone
who sounds friendly.
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DO Always state then spell
full details of: addressees, their full name, proper mailing
address; file numbers; reference numbers; patient record number;
subject matter.
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DO Try to use the same phrases
in each of your report types. Be consistent in the way you
approach similar reports. Make sure you use the same headings
whenever possible. This makes it easier to transcribe your work
and lessens the chance of error.
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DO Speak clearly and at a
regular pace.
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DO Pause slightly before
speaking when starting your recorder and pause briefly before
stopping recording. This prevents words from being “clipped.
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DO Speak with inflection in
your voice. Monotonal voices tend to put transcriptionists to
“sleep.”
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DO Speak with your mouth at the
recommended distance from your particular brand of microphone or
recorder for optimum sound levels.
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DO Edit-out any errors you
make, by rewinding and erasing them.
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DO Spell unusual words that
may represent diseases, drugs, or procedures not normally found
in the mainstream of your daily work or specialty.
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DO Always include punctuation,
especially when starting new paragraphs.
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DO Include “open” and “close”
quotation instructions.
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DO Have your dictation
equipment serviced at least yearly. Putting it in for service
during your vacation is a good time.
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DO
Get
a colleague's dictation digital audio file and spend just
one single hour trying to
transcribe his/her dictation as a transcriptionist would.
I absolutely
guarantee it will be an eye-opener.
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(back to top)
Dictation
Don'ts
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DO NOT Dictate in a noisy
area. Extraneous noise can make it difficult to hear dictation
accurately.
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DO NOT Mumble. Speak clearly
without letting your voice fade-out at the end of sentences.
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DO NOT Eat, drink or chew gum
when speaking. Sialogogues can be used to keep your saliva
flowing, if they are small and will not interfere with clear
speaking.
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DO NOT Make errors and then
say "strike that" or something to that effect. Use the "cue and
review" feature found on most current dictation equipment to
erase your last statement. Erasing your own error also negates
any chance of misunderstanding on the part of the
transcriptionist as to what was to be "struck" or erased from
what you dictated.
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DO NOT Try to spell words you
don't know how to spell. If the word is unusual, just say it as
clearly as possible and the transcriptionist can usually confirm
the spelling if required.
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DO
NOT
Say "period" for the end of a sentence. The proper phrase when
dictating is "stop" or preferably "full stop."
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DO NOT Shuffle papers, open
drawers, rearrange your desk, rip paper off examination tables,
or make loud sudden noises when dictating.
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DO NOT Forget to say "End of
Dictation" at the end of your dictation, so the transcriptionist
will know there is no more dictation at the end of the
tape/digital audio file.
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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.
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DO NOT Dictate while driving.
It's dangerous and the sound quality is usually poor.
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Confusing and/or
Sound-Alike Words
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Confusing and/or
Sound-Alike Words |
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accede:
stick to agreement
exceed: surpass |
accept:
receive
except: exclude |
adapt:
adjust
adept: proficient |
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adverse:
opposed
averse: not interested |
affect:
change, influence
effect: (v) to bring about (n) result, impression |
all right:
all right
alright: outdated usage |
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allude:
refer to indirectly
elude: avoid |
allusion:
insinuation
illusion: apparition |
already:
previously
all ready: everything prepared |
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altar:
place of worship
alter: to change |
appraise:
value
apprise: inform, notify |
assistants:
helpers
assistance: help |
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capital:seat
of government; money
capitol: building where legislative body meets |
cease:
stop
seize: apprehend |
cite:
speak of
sight: vision
site: location |
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complement:
collection
compliment: praise |
continual:
happens frequently in time: close succession
continuous: uninterrupted |
council:
praise
consul: ambassador
console: comfort
counsel: advice |
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descent:
decline
dissent: disagree |
disapprove:
condemn
disprove: discredit |
elicit:
extract
illicit: illegal |
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eligible:
qualified
illegible: indecipherable |
emigration:
moving from a country
immigration: moving to a country |
eminent:
outstanding, revered
imminent: threatening to happen soon |
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farther:
forward
further: additionally |
floe:
large sheet of floating ice
flow: move, run freely, circulate |
formally:
in a dignified way
formerly: previously |
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imply:
speaker implies (suggests)
infer: hearer infers (perceives) |
incidence:
occurrence
incidents: situations |
lay:
to set down, to place or put an item down
lie: to recline |
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passed:
go by
past: earlier |
principal:
first in authority; main participant; amount of a debt less
interest
principle: basic truth or assumption |
pray:
to ask for by prayer or supplication
prey: animal hunted or caught for food; victim |
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residence:
dwelling
residents: occupants |
right:
correct
rite: ceremony
wright: worker
write: compose |
their:
posessive form of “them”
they're: they are
there: at that place |
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stationary:
not moving: fixed
stationery: writing material: letterhead, envelopes,
etc. |
suit:
a set of clothes; legal action
suite: number of items making up a set, series, or
sequence |
waiver:
the giving up of a claim
waver: to hesitate; also tremble or quaver |
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through:
by way of
threw: tossed |
whose:
of or relating to whom
who's: who is |
your:
of or relating to you
you're: you are |
Here is just a
short list of words that should always be said clearly to avoid
errors:
·
adeno / adreno
·
fasciculation /
vesiculation
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has / had / have
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hema / hemo
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hyper / hypo
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in / an / on / and
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intra / infra
·
intra / inter
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is / as / has
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linguo / laryngo
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of / off
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para / peri
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pyelo / pyloro
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super / supra
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uretero / urethro / utero
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Numbers
Numbers are
sometimes a problem for inexperienced dictators.
Most "teen" numbers
can easily be confused with "ty" (pronounced "tee') numbers such as:
13/30, 14/40, 15/50/ 16/60, 17/70, 18/80. Dictating numbers properly
and in the accepted manner is a good way to avoid any
misunderstanding and is simple.
Here are some examples of how you should
say numbers:
Number Dictate
15 ........................... "Fifteen. That's one, five."
50 ........................... "Fifty. That's five, zero."
17 ........................... "Seventeen. That's one, seven."
When dictating
file numbers, medical numbers, Social Security etc...
Make sure you know the pace of the
number. By this, I mean a number that is listed as "1234 567
899" should NOT be dictated as 123, pause, 4567, pause, 899. Just
pausing between numbers, even if your pause is clear, as in "1234"
(pause) "567" (pause) "899," is not good enough, as the
transcriptionist still may not know where to place the spaces
between numbers. Rather, try to keep the pattern of the number as
well as stating the separating spaces, by saying "1234, space. 567,
space. 899." Proper "number pace" is important to transcriptionists,
as the number is more easily transcribed and is also more likely to
be accurately transcribed. (Try this: sit at your computer and have
someone tell you an unknown number of unknown length, without them
stopping, while you type it exactly as it should be.)
If you are
dictating a long number...
Keep
the numbers in groups of three or four, for easier transcription.
Very important also is the point that "0" (zero) is a number;
"o" (oh) is a letter. The number "506" should be dictated as "five,
zero, six," not "five, oh, six." This is of the utmost importance in
file numbers that include letters of course, as the transcriptionist
will consider all "o" sounds as the letter "o," and will transcribe
it accordingly.
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to top)
Overused Words
Part of good
dictation style is avoiding the use of unnecessary words...
Avoid redundancies
or grammatically-unacceptable phrases when dictating. It is more
professional to be as succinct as possible. Avoid "flowery"
language, too many superlatives, and over-used words and phrases.
Here is just a short list of what you should avoid:
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Wrong or Over-Used
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Try Using
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Very |
Avoid or use
sparingly |
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Very normal |
Normal |
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At this
point in time |
Now |
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At that
point in time |
Then |
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At the
present time |
Now |
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In the near
future |
Soon; specific
date/time |
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As per |
per; according
to; as |
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In close
proximity to |
Near; close
to; proximal |
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I am in
receipt of |
I have; I have
received |
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In the
matter of |
Regarding |
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Very near |
Near; close |
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Is on no
medication |
Is not on
medication |
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Resources:
http://www.medword.com/dictation.html
http://www.medword.com/dictation2.html
http://www.medword.com/dictation3.html
http://www.medword.com/dictation4.html
http://www.medword.com/dictation5.html
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