Friday, July 10, 2009

Narrating Your Notes -- Dos and Don'ts

In listening to more and more narrated notes, I have discovered that there are so many factors that can impair your scribe from being able to do a good job. So I thought that I would write about the Dos and Don’ts of narrating your notes.

Doctors' poor handwriting is a well-recognized source of medical errors, but their sometimes sloppy speech habits are a less well-known contributor. A study based on a sample of 220 dictated medical records totaling 9,726 lines of transcription found 27% of the 96 more-serious flaws were attributed to the speaker, typically a physician, and not the scribe. Twenty of 38 critical flaws (53%) and six of 58 major flaws (10%) were traced to the speaker.
Critical flaws include patient misidentification, medical word misuse and omitted dictation. Major flaws include misspellings and inappropriate blanks. Minor flaws include punctuation, grammar and formatting errors. [1]
  • Do speak clearly into the recorder or the phone. Hold the recorder or the phone about 3-4 inches from your mouth. If it is too close, the sound is not good at all and if it is too far way, then you may not be heard.
  • Do not eat, chew gum or drink while you are dictating. Sometimes these noises can be louder than you may think and the noise is amplified when you are wearing headphones typing a report.
  • Do spell out unusual places or names. This includes new medications, other Doctors names, patient names, etc.
  • Do not use punctuation. The medical transcription is trained in utilizing correct punctuation, grammar and spelling
  • Do dictate in a quiet place. Too much noise in the background is distracting and can cause blanks in a dictation.
  • Do your dictations when you're supposed to do them, and keep records of which ones you've done. It shows where to start looking for things if a dictation goes missing. Also, don't wait for six months to tell the MTs or nurse about mistakes.
  • It takes longer than 10 minutes to type a 30-minute dictation. It can take around two hours to type a 30-minute dictation. It takes longer for less experienced MTs or highly technical material. Giving the MTs 10 minutes to type a 30-minute dictation will get you disliked.
  • Only label dictations as stat if they really are stat. A transfer for cardiac surgery is stat; the provider wanting to go on vacation is not stat.

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