(This is a sample chapter from Dictation - An Art Within a Science by Ellie Jagiello, available as a Kindle eBook from Amazon. Buy Now on Amazon.)

Ours has become a society which does not really want to take responsibility for anything.  If we get a laceration from a kitchen knife, we sue the manufacturer because we were not told the knife was sharp.  Most of these claims go nowhere unless they are medically based.  Juries have been known to award horrendous amounts to “the innocent victim” of medical malpractice, even when there is no malpractice but merely a misunderstanding.  To avoid such a misunderstanding, your reports must be clear and concise with no room for your words (or lack thereof) to be turned into a monetary award.  This is not to say that malpractice does not exist for, unfortunately, it does.

When your patient comes into the hospital with a dog bite in his right hand documented in the history and physical, please do not, in the discharge summary, indicate that treatment included irrigation of the wound on his left hand.  Transcriptionists are supposed to transcribe what you say.  Some hospitals even instruct transcription companies to transcribe whatever is said, even if it is incorrect, and not to send any sort of notice to the dictator calling attention to what is seen as a problem.  The problem of  “wrong siding” in an emergency room note or history/physical is bad enough, but when it occurs in an operative report the problems are compounded, even if you have done surgery on the correct body part and side.

It is also important to be sure to dictate the correct medication.  You, the physician, should have full knowledge of what you are ordering or prescribing.  Some drugs are available in both oral and injectable form with the same name, some are not.  If you are ordering/prescribing an oral medication, make sure to use the name of the correct drug; i.e. Kefzol given intravenously would likely be changed to Keflex given orally on discharge.

(This is a sample chapter from Dictation - An Art Within a Science by Ellie Jagiello, available as a Kindle eBook from Amazon. Buy Now on Amazon.)

 In dictating medical records, more is not always better.  Too much detail, too many normal laboratory results, journaling rather than summarizing can lead to a report that is so lengthy it lends itself to not being read completely.  The one abnormal laboratory test, for example, buried in a page of normal results could easily be overlooked.  Just as your time is precious, as is the time of the person reading the report with an eye for continuing care, referrals, et cetera.

As noted previously, when you dictate the patient’s name you should dictate (and indicate) the first and last.  Avoid saying “common spelling” as there is really no such thing.  What is common to you may not be common to me.  For example, is it Ann or Anne?, Anna or Ana?, Louis or Lewis?  Be specific with names used in a report and especially with those you wish a copy to go to.  Is it Dr. Wolf, Wolfe, Wolff, Wolffe, or maybe even Dr. Wool?  If you are in a large city, do you really think there is only one “Dr. Smith?”  If your transcription is being done out of state, the transcriptionist probably will not know the specialties of any of these physicians and/or which of the five Dr. Wolfs specializing in internal medicine in your area is the patient’s primary care provider.  Also avoid saying “double _ _” as that is easily confused with “W.”

Please try to control your urge to spell everything.  Feel free to spell relatively new drugs and obscure diseases and laboratory tests (provided you spell them correctly), but it is not necessary to spell commonly used words/phrases.  Also control your urge to read an entire report (radiology, procedure, et cetera) into your report.  Refer to that report as being available in the chart, or request that a copy of the report be sent, but save yourself the time of redictating something that has already been done.  Including the whole thing in your report is a waste of your time and may cause confusion as to where the original report begins and ends.

However, if you feel it necessary to read something originally produced by somebody else, be sure to preface with “quote” and end with “end quote” because it is, after all, someone else’s thought/opinion.  The same is true of quoting anything else specific from the chart/patient.  Simply saying “quote, unquote” does not clearly indicate where the beginning and end should be (especially if reading a court petition or a referral).

Take a few moments before you begin dictation to review the chart and collect your thoughts on what you need to put into the type of report you are dictating.  Keep in mind, for example, that a discharge summary is just that, a summary.  If, at the end of your dictation, you remember something that you wanted to mention in an earlier section, be careful with your choice of words.  Saying “addendum” will bring a different result than if you say something like, “Please go back to ---.”  An addendum will most likely be typed at the bottom of the report.  Transcriptionists are supposed to do as we are told; if you say “addendum”, it will be just that.   “Please go back to --” does not always work if you try to add your thoughts after you have already finished your dictation and have gone on to something else.  At that point, anything you dictate will be transcribed as a separate report with a heading of “addendum.”

Dictating while you eat, yawn, or where there is a lot of background noise can lead to misunderstanding.   The first two scenarios are under your complete control.  As for dictating where there is noise, please do not lower your voice so as to not interrupt the party in the nurses’ station but rather raise your voice so that the transcriptionist can hear you.  If you must cough, sneeze, or clear your throat, please cover the microphone or at least turn away.  There is a pair of ears at the other end of that cough and while the germs may not be passed, what is heard sounds like a gunshot.  And, please, do not whistle while you turn pages as you look for information to include in your report.  A little consideration goes a long way in getting a complete report back to you

(This is a sample chapter from Dictation - An Art Within a Science by Ellie Jagiello, available as a Kindle eBook from Amazon. Buy Now on Amazon.)

As noted previously, the type of report you are dictating should be indicated right after you have identified yourself.  Most hospitals have their own requirements for specific types of reports.  It is the dictator’s responsibility to be aware of report types and what specific information should be included.  Indicating that a report is other than something on your hospital’s list of types could result in one of your charts being flagged as delinquent for lack of a specific report; i.e., if a “combined history and discharge summary” is not a choice, your printed report may indicate only “discharge summary” and you will be asked to dictate a history/physical.  While this type of error is quite easily corrected, it can eat up your valuable time unnecessarily.

It is a good idea to make consistency a part of your daily routine.  Keep like information together to insure that your report is clear.  Do not combine statements pertaining to past history, social history, and family history in one paragraph.  If necessary, create notes for yourself on the back of a business card to remind you what headings should be included and in what order.

With any type of report, if referring to another doctor, be sure that person really is a doctor.  There are nurse practitioners and physician assistants who perform the function of primary care provider in some practices.  When referring to a nurse practitioner or physician assistant, do so with a first name included when possible.  Simply saying something like P.A. Jones or N.P. Smith can result in your report going to Dr. Patricia A. Jones or Dr. Norman Paul Smith.

Generally, history/physical examinations contain the most information.  Start with the chief complaint or reason for admission.  From there, go on to the history of present illness, past medical/surgical history, medications, allergies, social history, family history, review of systems/symptoms, physical examination, laboratory data, impression/diagnosis, and plan of treatment/recommendations.   Additional headings may be requested or required for some specialties.  If your particular hospital has an outline of requirements, be sure to follow that; i.e., putting diagnosis/impression at the beginning of the report.

Consultations run a close second in the need for information, but do not always necessitate headings as such.  A consultation is not a letter, so do not start with “Dear Al.”  If you are seeing a patient in your office at the request of another physician, a letter may be in order.  If so, and if that letter is dictated through the hospital dictation system, be sure to dictate the name and address of the person to whom you are writing.  As mentioned earlier, transcription is often done many miles from your physical location so names and addresses may not be available.

Discharge summaries usually contain less information than a history/physical because you have already dictated the past history, medications, et cetera.  Keep in mind that a discharge summary is just that, a summary.  It is not a daily journal.  The notes in the chart made by anyone seeing the patient on a daily basis make up the journal.  Do not dictate a day-by-day account of the patient’s stay.  Do dictate a summary of the stay.  Be sure to include your recommendations for follow-up treatment and to review the most recent laboratory tests so that a follow-up physician/ancillary service is aware of what you feel the patient’s needs are.  Do not bury discharge medications in the body of the report.  Dictate a heading, then list medications with dosages and frequency.

A word about review of systems versus physical examination versus a review of symptoms:  Systems are, well, systems.  Symptoms are departures from the norm in structure, function, or sensation.  A physical examination is examination by means such as visual inspection, palpation, auscultation and/or percussion.  A review of systems should contain information pertaining to specific systems.  A review of symptoms should contain an explanation of the patient’s symptoms, usually in paragraph form.  A review of systems is basically a review of symptoms with dictated subheadings.  A physical examination should contain information pertaining to organs/regions.  The neck is not a system so should not be in a review of systems as a category, but it does contain the thyroid which is part of the endocrine system.  The thyroid can be felt, or not, within the neck and, therefore, “neck” can be part of a physical examination.  Cardiovascular would show up in review of systems; heart would be in the physical examination.  Respiratory is a review of systems entry; chest or lungs is the physical examination entry

When dictating laboratory data, be consistent.  Dictate either the test then the value, or the value then the test, but be consistent throughout each and every report.

(This is a sample chapter from Dictation - An Art Within a Science by Ellie Jagiello, available as a Kindle eBook from Amazon. Buy Now on Amazon.)

 If you have someone in your office dictating your preadmit reports to a hospital, be sure that they are kept informed of the hospital’s requirements, government regulations, et cetera.  Ultimately you are responsible for the accuracy of the report that bears your signature.  Most offices have been made aware of HIPAA requirements, but not all offices know the JCAHO standards for dictation.

(This is a sample chapter from Dictation - An Art Within a Science by Ellie Jagiello, available as an eBook from Amazon. Buy Now on Amazon.)

 Over the course of time, the frequent use of some phrases, procedures, events, et cetera, creates an abbreviation that is commonly recognized.  One example: MI is recognized as myocardial infarction.  In addition to abbreviations commonly recognized, most specialties create their own abbreviations.  Often the same abbreviation is used in different specialties with different meanings:  i.e., MR being mental retardation or mitral regurgitation.  Per JCAHO standards, each hospital is allowed to create its own list of “approved abbreviations.”  Additionally, the Institute for Safe Medication Practices (ISMP) has published a list of dangerous abbreviations relating to medications and instructions for use, and JCAHO has approved a “minimum list” of dangerous abbreviations, acronyms, and symbols that must be included on the “Do Not Use” list of each accredited hospital/organization.

If you must use abbreviations, be aware of what the abbreviation you dictate means.  For example, many dictate what sounds like “PERRL” or “PERL”.  This abbreviation starts with “pupils” so do not say, “Pupils are PERRL.”  The “P” in LEEP stands for Procedure, so stating “LEEP Procedure” is technically incorrect. Contractions also should be avoided.  “Can’t” really sounds like “can” when you dictate a sentence at top speed.

For transcriptionists, several reference books are available pertaining to abbreviations, acronyms, and symbols, some of which include notations of what the publisher considers “slang.”  Most transcriptionists are instructed not to use slang unless it is included in a direct quote  Because some books clearly identify slang terms and other books make no such identification, use of abbreviations should probably be avoided completely to ensure that any expansion that is required turns out to be what you intended.

Limited time only offer! Get the ebook Dictation: An Art Within a Science for just $2.99 from Amazon.

This offer ends on Saturday, January 22 so click now and take advantage of this great deal.

(This is a sample chapter from Dictation - An Art Within a Science by Ellie Jagiello, available as an eBook from Amazon or directly from your Kindle.)

 Before you begin dictating, be sure you know how the dictation system you are using works.  Usually you will need to input your ID number.  If you have been assigned an ID number by the hospital, be sure to use that number and that number only.  Your ID number may be linked to many things within the dictation system.  It may create the signature line on the report, it may trigger a copy to your office, et cetera.   And, it may be the only way the transcriptionist can identify you.  Speaking clearly and at a reasonable rate of speed starts here.  The work type you enter into the dictation system also may be linked to different things such as where the report will print within the hospital, as well as bringing up for the transcriptionist the template the hospital has assigned to that type of report.  If the hospital has certain required headings for certain reports, be sure to make yourself aware of those and comply with those rules and regulations.  Before you begin your actual report, dictate at least the following information:

• Your name
• If you are a resident, the full name of the physician you are dictating for
• Type of report
• Complete patient name, including middle initial, followed by spelling of both first and last name as well as identification of first/last (Allen Parker or Parker Allen)
• Patient medical record number and/or account number (as required by particular hospital, preferably both)
• Patient date of birth, age, and sex (Mr. Beverly Jones or Mrs. Beverly Jones)
• Date of admission, date of encounter, date of discharge
• Requesting/referring/attending physician
• Any other information required by specific institution

These data are generally found in the header/footers of each printed report.  Follow dictation system prompts and use only your own ID number.  Include the necessary information in your report, remembering that “necessary” includes complete physician names as well as decimals in laboratory values and medication dosages.  Refer to physician assistants and nurse practitioners with a full name rather than P.A. Jones or N.P Smith as “P.A.” and “N.P.” will more than likely be taken for initials.  Speak at a reasonable volume and rate of speed.

It is often difficult for the transcriptionist to determine the difference between a history/physical examination and a consultation.  If the report type is not indicated correctly, at some point in the next few weeks you may get a notice from medical records telling you that the patient’s record is incomplete because there is no consultation from you, when in fact it appears in the chart as a history/physical.  Again, the transcriptionist does not always have access to the actual chart or the demographics in the hospital’s computer and must rely on you to tell him/her what you are doing.

If you are a resident, indicate exactly who you are dictating for.  The physician signing the document is generally the attending/consulting physician.  The transcriptionist has no way of knowing who that is unless you identify him/her.  Consultants should also indicate the attending and/or requesting physician.

If you are an emergency room physician, be sure to include the date the patient is seen as well as the date the patient is actually admitted.  Many emergency room dictators dictate their reports at the end of the shift which may, in fact, be a different day.  The patient may have come in at 7 p.m. and may have been admitted at 10 p.m., but if you dictate after midnight the actual admit date needs to be indicated by you.   By the same token, some patients may require additional time in the emergency room, after having been seen by you and you having dictated your report.

Additionally, attending/admitting physicians should always dictate the date of admission, keeping in mind that the date the patient arrives in the emergency room may or may not be the date of admission.  Most attendings do not come rushing into the hospital at 11:30 p.m. to do an admit note, but rather wait until morning rounds.  Simply telling the transcriptionist what today’s date is may result in an incorrect admit date being entered into the patient’s records.  Some hospitals instruct transcription companies to use the date dictated as the date of admission (if a history/physical) or discharge (if a discharge summary).  Date of admission to the emergency room is not always the date of admission to the hospital.  When dictating time of admit, discharge, surgery, et cetera, be sure to indicate a.m. or p.m. or, ever safer, use military time.

When you have finished your dictation, be sure to indicate that you are finished.  There are many times when it is really difficult to determine if the dictation has actually been finished, or if the system has disconnected.  A simple “end of dictation” or “end of report” is all that is needed.

(This is a sample chapter from Dictation - An Art Within a Science by Ellie Jagiello, available as an eBook from Amazon. Buy Now on Amazon.)

 With few exceptions, dictation is transcribed in English.  If you require your dictation translated into some other language, you will probably have to find your own source to accomplish this outside the hospital setting.

Transcribing dictation with a strong foreign accent brings a challenge to most transcriptionists.  In addition to the accent, knowledge of general English “rules and regulations” plays a large part in the type of report you will get back.  English is by its very nature a difficult language to learn.  We have inconsistent pronunciation requirements for the same set of letter placements.  Our use of language is sometimes considered just plain bizarre.  Colloquialisms are, sometimes unfortunately, a way of life and speaking in the United States.  For example, “in the pink” has nothing at all to do with a patient’s mucous membranes.

When dictating with English as a second language, it is wise for you not to use colloquialisms unless you are absolutely certain of the real meaning of what you are saying.  At one point in my career as a transcriptionist, I was transcribing a report by a resident who was clearly not sure of what he was saying, dictating that a patient had been brought to the emergency room two days after an episode of “passing away at home.”  Obviously the phrase should have been “passing out at home.”  However, since the job of the transcriptionist is to type what is said, and not all transcriptionists pay close attention to the content of what they type, this sort of statement could show up in your finished report.

(This is a sample chapter from Dictation - An Art Within a Science by Ellie Jagiello, available as an eBook from Amazon. Buy Now on Amazon.)

Let’s face it, insurance companies do not want to part with their money any more than we do.  Insurance claims are sometimes processed by people who are not really “into” medicine.  Correct coding of the claim goes a long way toward getting you reimbursed for your time and efforts.  A vague report can turn into a vague code, one that may only be worth half of what you are actually entitled to.  If a claim is disputed, for whatever reason, it may take you months to get the proper reimbursement.  And, will you know the difference?  Again, abbreviations can cause confusion and sometimes lead to incorrect coding.  Often a coder does not have time to read through an entire report to determine the correct expansion of an abbreviation, or may not even realize that there are multiple expansions of the same abbreviation.  A discharge summary that lists no diagnoses creates a large coding quandary.  It is up to the physician to determine the diagnoses, not the coding department.

Within most transcription companies, transcriptionists are required to expand any abbreviations used in diagnosis and/or impression sections of a report.  Therefore, using full descriptions is the easiest and safest way to be sure that the conditions you treated the patient for are, indeed, what you are being reimbursed for.

To be sure you receive proper reimbursement, do not editorialize in the fields of diagnosis, procedure, or discharge medications.  These fields should be clean statements as they may be the only portion of your report used in determining your reimbursement.  Is it necessary to expand on these topics?  Probably yes, but do it in the body of the report, not where it can cause a diagnosis or procedure to be watered down.  While a patient may be admitted with a diagnosis of “rule out”, discharge diagnoses should be concise.  Whatever needed to be ruled out should, by the time of discharge, have either been ruled in (acute appendicitis) or ruled out (abdominal pain of uncertain etiology).  This is not an invitation to “pad” your billing, but rather a statement that you feel the patient’s admitting complaints/problems have been adequately addressed.

On surgical procedures, be sure to list each procedure done.  While there are some bundled procedures, there are also times when unbundling those procedures is appropriate.

It is your responsibility to clearly denote what it is you are seeking reimbursement for in a clear and concise manner.