PRACTICE POINTERS

How to be a supreme dictator

Good dictation habits improve patient care, lower malpractice risk, and boost income.

By Robert Lowes
Senior Editor

If you dictate your charts while munching on a ham sandwich, your medical transcriptionist won't understand what you said. If you try to sneak in dictation at your toddler's birthday party, your chart note will be disjointed and sketchy.

This seems obvious enough, but for too many doctors, it isn't, say the people who make their living transcribing doctors' dictation. Lousy dictation, like lousy handwriting, is detrimental to your medical career. Transcribed chart notes that are filled with errors or are incomplete can jeopardize patient care and increase your malpractice risk.

Poor dictation also hurts your bottom line. For one thing, it undermines your efforts to maximize revenue. Inadequate documentation may force you to settle for lower-paying CPT codes, and chart notes with gaping holes won't weather insurers' coding audits.

For another thing, poor dictation drives up costs. When your in-house transcriptionist has to play over your dictation 10 times to determine if you said hypothyroidism or hyperthyroidism that's a waste of her time and your payroll.

Even if you outsource dictation (and pay by the line, not the hour), garbled dictation may slow down the transcriptionist's turnaround time. And you're bound to get back a document littered with blanks where the transcriptionist was at a loss for your words. You'll have to take time out of your schedule to fill in the blanks—assuming you remember what you said.

But will you really make the time? Transcriptionists say many doctors live by the motto "dictated but not read," which makes it even more important to get it right the first time.

For good dictation, think before you speak

Too many doctors plunge headlong into dictation without collecting their thoughts. The result is a long, sometimes illogical, stream-of-consciousness report that boosts the line count and the transcription charge. When these disorganized dictators ask the transcriptionist to make changes, that lengthens turnaround time.

So pick a quiet place to dictate. "Doctors who dictate where it's noisy lose their train of thought," says Carole Gilbert, who owns a medical transcription company in Casselberry, FL. Then think before you speak. Every dictation should start with this essential information:

•Spelling of the patient's first and last name.
•Patient's date of birth.
•Date of the visit or service.
•Number of the medical record.
•Spelling of the name of the referring or consulting physician—first name, too.

To organize dictation, Susan Holzem, chief operating officer of Stat-Med Transcription in St. Louis, advises doctors to follow a standard charting format, such as the SOAP note. A printed office-visit form can guide you through it. Using a special template like this for physical exams and lab reports also streamlines your work (see "Cut down dictation time with templates").

One fan of organized and thorough dictation says it permits his chart notes to reflect his medical reasoning. "If I talk to a patient about selecting medications, I'll dictate the medications we discussed and explain why some aren't good choices," says St. Louis rheumatologist Richard Brasington. "We may have vetoed a perfectly good drug because it required intravenous delivery, and the patient found it too uncomfortable. I might not remember that otherwise when I see the patient a year later. And the chart note explains my rationale to other doctors, too."

Brasington also dictates with reimbursement in mind. "I avoid general statements such as 'The patient is here for a scheduled appointment,' " he says. "An insurance company might construe that as an unnecessary visit. But if I say, 'The patient returns for re-evaluation of her rheumatoid arthritis,' I have better support for my coding."

To produce such detailed reports, it's best to dictate immediately after you've seen the patient. If you do all your dictation at 5 pm, you're bound to forget critical facts.

A transcriptionist can only transcribe what she hears

Three factors determine good sound quality: the speaker's delivery, his equipment, and background noise.

Delivery. Good enunciation is crucial, especially with sound-alike words. Did the doctor say "fifty" or "fifteen"? "Xanax" or "Zantac"?

It's hard to enunciate if you talk as fast as an auctioneer. Sue Holzem wishes more dictators would slow down. "A lot of doctors don't like to dictate, so they try to say the most in the least amount of time," she says.

Medical transcriptionists also complain about doctors who dictate while they eat lunch—another enunciation no-no. Try saying "glomerulonephritis" with yogurt in your mouth. Other pet peeves: speakers addicted to saying "uh," and the soft-spoken. "Please resist the urge to whisper when you are talking about sensitive subjects such as a patient's pelvic exam," says one West Coast transcriptionist in an online posting.

One cure for hard-to-understand doctors is to listen to their own dictation. If that doesn't work, have them listen to another poor dictator, advises transcriptionist Mary Bain in Scottsdale, AZ. "This may be an eye-opening—or mouth-opening—experience," she says.

Equipment. Poor dictation often stems from operating the tape or digital recorder improperly. Medical transcriptionist Renee Priest of Sanford, FL, knows a urologist who continually whacks out entire words and sentences of dictation because he can't control his device's stop button. "His reports routinely have five to 10 blanks, sometimes as many as 20," she says.

Other doctors turn up the volume too high or change the speed setting on tape recorders. Or they dictate into a tape recorder and then play the recorded dictation into a telephone. Mechanical noise from the tape recorder can muddy the dictation.

For the best sound quality, maintain your equipment. Keep recording devices stocked with fresh batteries, and clean your tape recorder periodically to prevent grime from causing snaps, crackles, and pops that drown out what you say.

Background noise. Be careful what you do with your hands. Transcriptionists struggle to decipher the words when dictators rattle papers or X-ray film. Also be careful about where you dictate. The urge to multitask leads doctors to dictate in some of the noisiest settings imaginable. Transcriptionists swap stories of doctors who dictate while they watch war movies on television, wash dishes, or supervise screaming kids.

Ideally, you should retreat to your office and close the door. If you're like most doctors, though, and find yourself dictating on the run, minimize extraneous sounds. For instance, if you're in the hospital, avoid dictating next to beeping monitors.

Many transcription services allow doctors to dictate into phones. If you do, don't use the speakerphone option. It picks up whatever else is going on in the room.

Dictating in a car creates its own set of problems. "Doctors stuck in rush hour traffic will try to do a few charts, but they'll have the radio on, and their windows rolled down, and the cars around them are honking like crazy," says Holzem. Dictating into a cell phone behind the wheel is especially dicey, she says, because you can't count on good reception.

Understand transcriptionists' limitations

You have to understand how your transcriptionist works, so you'll recognize what she can—and can't—do. For example, some companies insist that employees take down dictation verbatim and not engage in any time-consuming editing to fix problems, says Peg Hughes, professional practices director of the American Association for Medical Transcription. Other transcriptionists operate under AAMT guidelines that permit light editing to improve clarity, accuracy, consistency, and completeness, she says.

However, when dictation contains nonsensical statements such as "Duration of illness is probably at least since he became ill" (this comes from an actual transcript), even a transcriptionist who's allowed to edit may record the blooper verbatim and flag it for the doctor's review, she says. And remember, when you outsource, the transcriptionist can't look up anything in the medical chart to correct or amplify a report.

Although transcriptionists are schooled in medical terminology, that terminology is constantly changing. So when you mention a new drug or medical instrument, assume the transcriptionist hasn't heard it before, and spell it out.

Sue Holzem asks dictators to spell out their preferences for how a finished transcript should look. "I prefer doctors who are very picky, because once you learn their standards, it's very simple to do it their way," she says.

Be considerate. Transcriptionists have to earn a living, so don't slow them down with acts of carelessness. If you're dictating and a nurse interrupts you to talk about a patient, turn off or pause your recording device. Otherwise, the transcriptionist has to waste time listening to this conversation.

Finally, if you really want a transcriptionist in your corner, take a few seconds to say something kind to her. "I have one doctor who is my favorite because he thanks me for my hard work," says transcriptionist Mary Bain. "I'll do his dictation any day."

Cut down dictation time with templates

How many times have you listened to someone's heart and later dictated, "Regular rate and rhythm. Normal S₁, S₂, No S₃, or S₄. No murmurs, gallops, heaves, or rubs."

Now think of all your system reviews, tests, and X-rays that involve normal findings such as these. They represent a lot of standard and time-consuming verbiage.

You can automate this aspect of dictation by working with your transcriptionist to create templates for various elements of the patient record. For example, give her a script for your normal physical exam. She can create a word processing "macro" that lets her copy this script into a transcribed report with just a few keystrokes. All you have to do is say "physical exam" during dictation, and merely state the abnormal or positive findings.

Besides speeding up dictation, templates help transcriptionists turn work around more quickly. Templates may reduce transcription costs, too. Some companies charge only for the macro keystrokes that produce the template. When transcriptionists are employees, the increased productivity possible with templates accrues directly to you.

Doctors say the darndest things

Transcriptionists enjoy a good laugh, and they get plenty just listening to what doctors say. Kelly Ratzlaff, a transcriptionist in Eureka, CA, has posted the most nonsensical or inadvertently humorous statements she's heard on her Web site at www.kellyandkevin.com .

"I will remove the tonsils, and while under anesthesia I will inspect the adenoids as well."

"His appetite is excellent. He eats three meals a day with relish."

"Exam reveals a gentleman in no apparent distress except when having his left lower extremity examined or removed."

"First name Victor, spelled V as in Victor . . ."

"I have been following him because of his paranoia."

"She is careful when talking about her husband and her gag reflex is normal."

"Also, on his right hand he has a left thumb dislocation."

"Next patient is San. . . . San. . . . something-or-other."

Blabbering costs money

In the quest for thoroughness, don't succumb to wordiness, which inflates the transcription bill. One transcriptionist tells of a doctor who wasn't content to say "we closed the wound . . . " but expanded the statement to, "we then proceeded to close the wound . . . ." In a recent dictation, this verbal tick appeared 22 times, says a transcriptionist in a posting on an Internet forum for her profession. "He is also fond of 'with this in mind, we then. . .'," she says.

How costly is this wordiness? Saying "then proceeded to" adds 17 characters (including spaces)—or 374 characters when repeated 22 times. If a transcriptionist charges, say, 13 cents for a 65-character line, this pet phrase in just one report could cost about 75 cents. Over a year, this doctor could be talking away hundreds of dollars.

 

Robert Lowes. Practice Pointers: How to be a supreme dictator. Medical Economics 2002;17:69.