Medical transcription: Why is dictation an important part in medical record creation?

Why document the patient-doctor encounter?

The documentation of the patient-doctor encounter takes place for a number of reasons, some of which are given below:

1. Records provide the medical history of the patient enabling healthcare professionals to administer the best care possible.
2. It is legally mandatory to maintain patient records.
3. Patient records provide the basis for referrals
4. Patient records are the basis on which insurance claims are made
5. Patient records provide evidence in case of malpractice suits. 

Having looked at the importance of having to create medical records, now the focus is on the process of record creation. Medical transcription plays an important part in the speedy and accurate creation of medical records. The medical transcription process starts when the doctor dictates notes of the patient encounter into a recording device.

Many people have questioned the necessity of the doctors dictating notes rather than directly typing out the reports. Let us examine why dictation is necessary:

Time: Time is a scarce commodity for healthcare professionals and dictating free style could be squeezed in at any time of the day, and would not require any equipment other than their phone.  Dictating notes would also take less time than actually typing as it has been proven than people can talk faster than they can type.

Expertise: The skill set of a doctor may not necessarily include typing speedily and accurately.

Speed: A medical transcriptionist could have better typing speed than a doctor. Moreover the creation of patient records would be speedier by medical transcriptionists as this is their only work; therefore the focus is totally on this.

Ease of use: It is easier for the doctor to dictate into his recording device while doing other things than to sit and type out the report.

Expense: It is cheaper for a medical transcriptionist to transcribe the report rather than the doctor waste his expertise and productivity on this task.

It is therefore better for doctors to focus on their business; providing quality healthcare and for the medical transcription service provider to focus on their business; Expert medical transcription and medical record creation. 

How to improve dictation quality?

We have looked at the advantages of dictating vis-à-vis typing, now let us focus on how dictation can be improved to improve the accuracy of the transcribed reports: 

Given below are a few dictation tips towards accurate medical transcription:

• Allot time for dictation: This will help the doctors to complete documenting the patient encounter when their memory is still fresh and capture all the details.

• Allot space: Allotting a convenient space for dictation will ensure that factors like noise, distractions do not affect the quality of recording.

• Collect papers: Collecting all the documents/reports required will help the doctor finish dictating accurately in less time.

• Speak at a steady pace: Speaking a steady pace will ensure that words are not garbled and help the medical transcriptionist focus.

• Spell difficult terms: Spelling difficult terms will ensure that the data captured is accurate.

• Rewind and listen: Sometimes rewinding oneself and listening to the dictation will help clarity by highlighting the areas for improvement.

• Know the equipment: Knowing the equipment being used for dictation will help the doctor to modulate his dictation, mike distance, stop/start features etc.

• Relax while dictating: Treat the time spent dictating, as time for a break and this will help the doctor relax and capture all details.

• Pause during interruptions: In case of any interruptions, it is better to use the pause button so that extraneous data is not captured. 

Following these simple instructions will go a long way to help create accurate transcripts at an optimum turnaround time

TransDyne offers quality medical transcription at reasonable prices, done by expert medical transcriptionists with a very quick turnaround time executed through secure HIPAA & HITECH compliant channels, with very high levels of accuracy and all this with technology that is advanced but easy to use!

For more details about how to use TransDyne’s superior outsourced medical transcription services, click here.