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Marinda Thayer

Mobile:  360.749.2155

ThayerMT@ThayerTranscription.net

Dictation Tips

 

 

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

 

  • 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.
  • DO Assemble any papers, reports, before you start dictating.
  • DO Make sure you are in a quiet area so your dictation can be heard clearly by the transcriptionist.
  • 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.)
  • 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.
  • DO Always state then spell full details of: addressees, their full name, proper mailing address; file numbers; reference numbers; patient record number; subject matter.
  • 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.
  • DO Speak clearly and at a regular pace.
  • DO Pause slightly before speaking when starting your recorder and pause briefly before stopping recording. This prevents words from being “clipped.
  • DO Speak with inflection in your voice. Monotonal voices tend to put transcriptionists to “sleep.”
  • DO Speak with your mouth at the recommended distance from your particular brand of microphone or recorder for optimum sound levels.
  • DO Edit-out any errors you make, by rewinding and erasing them.
  • DO Spell unusual words that may represent diseases, drugs, or procedures not normally found in the mainstream of your daily work or specialty.
  • DO Always include punctuation, especially when starting new paragraphs.
  • DO Include “open” and “close” quotation instructions.
  • DO Have your dictation equipment serviced at least yearly. Putting it in for service during your vacation is a good time.
  • 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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Dictation Don'ts

 

  • DO NOT Dictate in a noisy area. Extraneous noise can make it difficult to hear dictation accurately.
  • DO NOT Mumble. Speak clearly without letting your voice fade-out at the end of sentences.
  • 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.
  • 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.
  • 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.
  •  DO NOT Say "period" for the end of a sentence. The proper phrase when dictating is "stop" or preferably "full stop."
  • DO NOT Shuffle papers, open drawers, rearrange your desk, rip paper off examination tables, or make loud sudden noises when dictating.
  • 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.
  • 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.
  • 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

 

Confusing and/or Sound-Alike Words

accede: stick to agreement
exceed: surpass

accept: receive
except: exclude

adapt: adjust
adept: proficient

adverse: opposed
averse: not interested

affect: change, influence
effect: (v) to bring about (n) result, impression

all right: all right
alright: outdated usage

allude: refer to indirectly
elude: avoid

allusion: insinuation
illusion: apparition

already: previously
all ready: everything prepared

altar: place of worship
alter: to change

appraise: value
apprise: inform, notify

assistants: helpers
assistance: help

capital:seat of government; money
capitol: building where legislative body meets

cease: stop
seize: apprehend

cite: speak of
sight: vision
site: location

complement: collection
compliment: praise

continual: happens frequently in time: close succession
continuous: uninterrupted

council: praise
consul: ambassador
console: comfort
counsel: advice

descent: decline
dissent: disagree

disapprove: condemn
disprove: discredit

elicit: extract
illicit: illegal

eligible: qualified
illegible: indecipherable

emigration: moving from a country
immigration: moving to a country

eminent: outstanding, revered
imminent: threatening to happen soon

farther: forward
further: additionally

floe: large sheet of floating ice
flow: move, run freely, circulate

formally: in a dignified way
formerly: previously

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

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

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

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

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

·                    has / had / have

·                    hema / hemo

·                    hyper / hypo

·                    in / an / on / and

·                    intra / infra

·                    intra / inter

·                    is / as / has

·                    linguo / laryngo

·                    of / off

·                    para / peri

·                    pyelo / pyloro

·                    super / supra

·                    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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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:

 

Wrong or Over-Used

Try Using

Very

Avoid or use sparingly

Very normal

Normal

At this point in time

Now

At that point in time

Then

At the present time

Now

In the near future

Soon; specific date/time

As per

per; according to; as

In close proximity to

Near; close to; proximal

I am in receipt of

I have; I have received

In the matter of

Regarding

Very near

Near; close

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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