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Dictation Best Practices
A Guide for Physicians
Dictation Best Practices
A Guide for Physicians
Presented
by the
American Association for Medical Transcription
Sponsored by
Why Do You Dictate?
Documentation is an Essential
Ingredient of Good Medical Care
Good Documentation
 Accurate
 Complete
 Available
When Needed
Quote or Quill
Dictation is an effective and
economical way to convey the
patient’s story
The Challenge
Communicate clearly and succinctly
Partners in Quality
Medical Transcriptionists are
documentation experts and
your partner in creating the
required record of care—
accurately and efficiently.
Impact of Dictation
Documentation errors
 Patient Safety
 Sentinel Events
 Turnaround Time
 Costs

Patients at Risk
Poor dictation can result in the
omission of very important words such
as “no” or “non”, as in “there is (no)
malignancy identified”
US Leads in Medical Errors
“Thirty-four percent of U.S. patients received
wrong medication, improper treatment or
incorrect or delayed test results during the last
two years, the Commonwealth Fund found.”
US Leads Way in Medical Errors, S. Heavy, Common
Dreams, November 23, 2005
View of the Courts
According to the Wisconsin Supreme Court
“We hold only that hospital records bear
such an unusual indicia of reliability and
trustworthiness that … such records satisfy
the confrontation clause.”
Good Dictation
Improves communication among
caregivers
 Promotes patient safety
 Reduces turnaround time from
dictation to charting
 Ensures uncompromised reports
as legal documents

Poor Dictation
Leads to errors in transcription
 Puts patients at risk
 Slows and/or reduces
reimbursement
 Impacts timely delivery of care
 Increases administrative and
transcription costs

Problematic Dictation
Incorrect verbiage or grammar
 Rapid speech
 English as a second language
 Articulation
 Insufficient volume
 Background noise
 Incorrect or insufficient patient information

Turnaround Time
Quality patient care demands shorter
turnaround time
 Problematic dictation can double or
triple time spent transcribing
 Several problematic reports
can affect timely delivery of
all reports

Costs
Inferior dictation increases
administrative costs
 Inadequate dictation decreases or
delays reimbursement
 Poor dictation can increase
turnaround time,
delaying treatment

Dictation
Requires special attention to
clarity and style
 No visual clues (lip movements,
facial expressions)
 Asynchronous communication
 Lacks flow and rhythm of
conversations
 More difficult to comprehend

Speech Recognition
Realizing higher adoption rates
 Incapable of completely replacing
transcriptionists
 Unable to interpret vast majority of
dictators
 Requires more attention to
organization and articulation

Environment

Monitor background
distractions such as voices,
telephone ringing, and/or
music

Avoid side conversations
Background Noise
He had three recent _____ procedures
and is seeing a cardiologist.
Organization

Organize data before
dictating

Follow established templates
Disorganized Dictator
Chest wall showed tenderness on
pressing on the right lateral and anterior
ribs area. Back showed kyphosis.
Heart S1, S2.
Equipment
Refer to tip sheets for proper use of
dictation equipment
 Use correct hand-held settings to avoid
clipped words
 Hold the mic the proper
distance from the mouth

Too Close to Microphone
At that time, her chest x-ray ____ a new
finding of ______ atelectasis which I felt
was due to her residual RSV bronchiolitis.
“Puffing” the Mic
Babinski and no clonus ____ in the
upper and lower extremities. Her motor
is normal. Her sensation is decreased in
the C6 distribution on the left. She does
have a positive Tinel sign over the
median nerve but a negative Phalen sign.
Demographics
Key identifying information
when prompted
 State and spell the patient’s
name
 Include at least one other
patient identifier (i.e., birth
date or MRN)
 State the date of service

Courtesy
Avoid eating and chewing
gum
 Pause while yawning,
coughing or sneezing
 Remember! We can hear
what you wouldn’t want us
to hear!

Yawning
Back pain ____________. Past
medical history is negative.
Surgery negative.
Speech
The dictator’s speed and poor
articulation were cited as being
the most frequent causes of
problematic dictation.
Key Syllables

“No” or “known”

ABduction or ADduction

hyPO or hyPER
Abbreviations
Avoid uncommon abbreviations
 Use abbreviations from facility’s
approved list
 Give clues when dictating common
abbreviations

BMP versus BNP
 CNS versus C&S

Numbers
Dictate numbers clearly and
succinctly
 Differentiate “fifty” and “sixty”
(e.g. five-oh, six-oh)
 Delineate vital signs and lab
values with test names

Running Numbers Together
Temperature is 98.3, 120/60, 105,
16.
Medications
Carefully dictate
medication names and
dosages, especially those
with sound-alikes
(e.g. Endal, Inderal;
MiraSept, Mircette)
Feedback
Return notations on blanks
or incorrect areas of the
document to the
transcription staff in order
to prevent errors in the
future
Dictation Tool Kit
Dictation Fact Sheet
 Dictation 101
 Model Policies and Procedures
 Sample Q Cards
 Feedback Letter
 Tip Sheet

www.AAMT.org
The Bottom Line
Good quality dictation
and transcription is winwin for the patient, the
caregiver, and the
facility’s bottom line
Contact
American Association for Medical
Transcription
www.aamt.org
800-982-2182
Sponsor
MedQuist is the leading provider of clinical document
workflow solutions. MedQuist provides document workflow
management, digital dictation, speech recognition, dictation
devices, Web-based transcription, electronic signature,
medical coding and outsourcing services.
MedQuist Inc.
Corporate Offices
1000 Bishops Gate Blvd.
Suite 300
Mount Laurel, New Jersey
08054-4632
Phone: 800-233-3030
Fax: 856-206-4020