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Enunciation is among the most important requests we can make. Clearly speaking the dictation is most helpful especially on words that are critical in your document such as: right vs. left; positive vs. negative; non-sustained vs. sustained; increased vs. decreased; etc.
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Spelling the names of patients and referring physicians will decrease the amount of hands-on work your staff has to do when the document arrives back in your office. If we place a phonetic spelling in the document and bold or underline it because we are not sure, then someone at your office has to follow-up on that. What a help it would be if these names were spelled for us by you when you dictate. Always remember, if you can’t pronounce it, we probably can’t spell it J
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Working through the template methodically is a help as well. When you jump around in the dictation dictating part of the history, then the exam, then back to the history, then to labs, then back to the exam…..it leaves too much open to the transcriptionist’s interpretation of exactly where you want which statement. You are the leader, we are the follower. Keep a copy of your template, or a “sample report” you can use as an example which will help you remember what we are seeing on our screens as we transcribe. It will aid you in “what comes next”.
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Telling us the date you wish to be on the dictation will give your document an accurate date for when the patient was seen; for when the test was done. Patients seldom remember exact dates, but these are critical for proper documentation of medical care administered for an accurate medical history, and for insurance reimbursement.
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When giving acronyms in your dictation, it is helpful if you could give us an example of the letter you are giving. In a sound file, a B sounds like D, V, and P; and N and M are also difficult to distinguish. We don’t mean to make mistakes; sometimes we just cannot tell what is being said, and the problem with acronyms is many of them are the same in certain areas of medicine so its really better not to give them anyway.
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Please keep in mind that when you have things in your mouth such as candy, chewing gum, or your lunch, it becomes very, very difficult to understand what is being said. Also, when you continue to try to dictate through a cough, sneeze, or yawn, you are likely to have holes in your dictation. We hate turning back a document that looks like Swiss cheese, but when we can’t make out a word through your chewing, yawning, or choking we have to leave a blank.
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Remember the mechanics of recording. Please press the button first … before talking. Many blanks are left at the beginning of sentences because the dictationist doesn’t have the record button down. Keep in mind the distance you are away from the microphone. Too far away picks up too much background noise or static, and makes you very difficult to hear. Too close causes your “s” and like consonants to “explode” and also makes it sound like you are mumbling…..we need you to be “just right” as in the fairy tale, The Three Bears. J And try to remember, not to block the microphone with your hand, the patient’s chart, etc.
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If you are using a handheld digital recorder or cell phone, please change/charge the batteries regularly. Poor battery charge will give extremely bad sound quality.