Download 2008_09_11-Lalani-Dictation_of_Consult_Note

How to Dictate Consult Note
Nadim Lalani MD
Who took dictation in school?
Dictation
o the transcription of spoken text:
• one person speaks while the other writes down the
words as they are spoken.
o la dictée : a school exercise aimed at testing the
mastery of orthography and grammar.
o Some countries (e.g. France) hold dictation
championships.
o Call the 1-800 number for your Dell and imagine
having to transcribe what that person is saying!
Why Bother?
o Patient Safety [esp when changing regimen]
o Improved patient care
o Improved relations with colleagues
o Feedback to consulting colleague
o If you’re billing a consult you should be doing
this.
o Essentially a reflection of your
professionalism.
ABC’s of a Dictation
o Dial 944-4444 [or local 44444]
o [British]computer will prompt you for
• Your College ID [basically your Alberta License # with no letter]
• Work type
o 34 = emerg assessment
• Site Identifier
o
o
o
o
ACH = 91
FMC =92
PLC = 93
RGH = 94
• Patient Number
o Pressing 2 starts & pauses
o Pressing 3 rewinds [you can then record over mistakes]
o Pressing 5 ends dictation
Mandatory Inclusions
o YOUR first and last name
o the first and last name of the attending
physician.
o the first and last name of the patient.
o the ENTIRE 10-DIGIT patient number
o Date of visit
o Diagnosis/Results/Procedures
o the first and last name of physicians copies
need to be sent to.
The Art of La Dictee
o How about “good morning... And thank you”
[you’re talking to a person not a computer]
o Spell out all names [and give specialties of MD’s]
o Spell out all medical terms
o Spell medications, give the dose and regimen
o GIVE PUNCTUATION “ begin new paragraph.
Period. Colon....&c.”
o Visualise the note taking shape infront of you.
Questions?
Do’ not a be dictator bad