Tips for Medical Transcription Dictation

Years back when I was in India, I knew a pharmacist who was the only one who could decipher everything our hospital's only physician scribbled /prescribed on his pad. (Many rural Indian hospitals still follow the system). Believe it or not, whenever the pharmacist took a day off or was on leave, the pharmacy would give out wrong medications that turned up to be tragic. We later solved the problem by getting a mobile phone for our pharmacist friend whom we called up even on his "off days" and clarified what the physician prescribed. Surprisingly he could solve the problem even over the telephone.

Today it is not bad handwriting but bad dictation. It indeed makes the medical transcriptionist's job more difficult and highly prone to mistakes. Further it causes waste of valuable time. So what can be the solution to this problem? Is it possible to have an exclusive transcription professional for each doctor so that he gets know the physician like the back of his hand?

Well here is a guide with tips to proper dictation that will be very useful for the physician to give good dictations and get error free transcripts. I recently came across a group of medical transcription from different specialty groups who all had similar types of requests/appeal for the dictating physicians /doctors.

• While dictating a difficult medical term it would be greatly appreciated if care is taken to see that the term gets well recorded via the microphone.
• Please start the dictation mentioning about the type/title of document that is been dictated instead of keeping the transcriptionist guessing about it till the end.
• Please avoid the tendency to summarize every thing/procedure and include everything in few long sentences. It would be ideal to present the facts in shorter and more communicative sentences if possible.
• Would appreciate if uncommon abbreviations are expanded and dictated when possible.
• Please move your face away for a moment from the microphone to sneeze/cough.
• Please finish your snack before beginning the dictation or keep it for afterwards.
• Never forget to mention the basic information like date/name/ summary etc
• Try and avoid talking fast/ yawns /hiccups while dictating.

Physicians/surgeons should be aware of the background sounds/ noise and how it can become a hindrance to listening to the dictation. Just a pause at such occasions would be greatly appreciated and can save a lot of time.

Outsource Strategies International(OSI) is a US based medical transcription company that offers outsourcing solutions in medical billing, medical coding and medical transcription service for clients globally.

Medical Transcription Professional: See Where He Comes In!

You are not well and have decided to see a specialist about that nagging pain. You go and start talking about the problem to the doctor. Now you may need to talk about the past history of the problem which you will have to remember and maybe rack your brains to remember everything just as it happened. (Ideally you must have some past papers and also made specific notes about the problem).

Anyway, after you have explained your problems and also answered all the queries of the doctor, he will physically examine you and also prescribed for various laboratory tests before he is able to make a diagnosis/differential diagnosis. Only after diagnosis does the doctor comes up with the plan of treatment which he explains and gives you / your family members the required instructions/prescriptions that must be followed. Finally as you come out of the doctor's office, you see the other people waiting for their turn to get in and talk to the doctor. But before someone else walks into the doctor's cabin there is something the doctor does after you have left. Well it's just that the entire encounter he had with you is quickly recorded into a voice recording device (either a cassette recorder, telephone or some other device).

In a few minutes the doctor is on to another patient, another issue and thus the voice recordings continue. By the end of the day/session the doctor has seen many patients requiring various types of treatments. Now where is all that critical patients' data? Can we expect the doctor to remember some of the details? Certainly not! Well as of now, most of the information is on tape and tomorrow the doctor or someone else (like say the insurance people) may need to know exactly what happened with say, patient number 6 who came in last Monday?. Should they be given access to those voice recordings? Can they follow the doctor's rumblings? No indeed, everything has to be neat, and in paper. But then the doctor can't type nor does he have the time for paper work. So who does all that work of converting that technical "doctor talk" into a typed document? You guessed it!

OSI (Outsource Strategies International) is an Oklahoma based domestic and offshore outsourcing solutions provider, for medical transcription, medical billing and coding.