Hot off the presses, my colleague Janice Jones and I contributed to an article on how healthcare documentation specialists (HDS) can address problems with dictation in this month’s For the Record magazine. The tips and tools discussed in the article are great for those who process the dictation via traditional transcription or editing of speech-recognized text. However, I would like to focus this post on best practices for dictators. Good dictation habits are a huge help to the team that provides transcription and editing services, and clear, complete dictation improves efficiency and quality like nothing else. So, to avoid the “back-and forth” with healthcare documentation services and clinical documentation improvement, here are some tips to consider.
- Be careful when entering demographics. Most dictation modalities (phone, speech mike, etc.) enable the dictator to type in and/or search for the appropriate document type, patient identifiers, dates, and other demographic information. Take care to select the correct “John Smith” and the appropriate visit to ensure that the document is linked to the appropriate electronic record when it is completed.
- Use the optimal recording device for your environment in the optimal way. If you typically dictate in a noisy, busy department, dictating on the move on a mobile device may not yield the best sound quality or ensure HIPAA compliance. Work with your documentation team to determine what best fits your environment, workflow, and preferences. Then get training on the device and/or read the manual. Taking the time up front to get comfortable with the device and environment will save a lot of time in the long run.
- Speak at conversational rates. You may be in a hurry, but remember that you are telling the patient’s story to another human being, and it is being recorded for posterity, so you want it to be clear, concise, complete, and correct.
- Clearly pronounce and/or spell sound-alikes (there are many homonyms in health care), as well as new terminology, drugs, equipment, unique names, and locations. This will assist the HDS in making proper selections and extending their knowledge.
- Get training on speech recognition best practices and coaching to address any questions or concerns about using new dictation tools and software. Set aside some time for optimizing the configuration so that you will be able to get the most benefit (and the least frustration) from the technology.
- Know the required content for each document type and adhere to your organization’s standards. Enlist the assistance of an HDS to develop templates when appropriate to help with efficiency, consistency, and completeness.
- Resolve all blanks and flagged content before final authentication (to avoid addenda and queries), and then provide feedback on how they were resolved (especially if they are recurring blanks or flags) to the healthcare documentation team. Any feedback intended to increase knowledge is helpful, so take some time to communicate your preferences and comments so that you and the HDSs who support you will be on the same page.
Jill Devrick is the AHDI President and a Product Solutions Advisor with 3M Health Information Systems.