Post on 10-Feb-2016
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How to Dictate Consult Note
Nadim Lalani MD
Who took dictation in school?
Dictation
o the transcription of spoken text: • one person speaks while the other writes down the
words as they are spoken.o la dictée : a school exercise aimed at testing the
mastery of orthography and grammar. o Some countries (e.g. France) hold dictation
championships.o Call the 1-800 number for your Dell and imagine
having to transcribe what that person is saying!
Why Bother?
o Patient Safety [esp when changing regimen]o Improved patient careo Improved relations with colleagueso Feedback to consulting colleagueo If you’re billing a consult you should be doing
this.o Essentially a reflection of your
professionalism.
ABC’s of a Dictationo Dial 944-4444 [or local 44444]o [British]computer will prompt you for
• Your College ID [basically your Alberta License # with no letter]• Work type
o 34 = emerg assessment• Site Identifier
o ACH = 91o FMC =92o PLC = 93o RGH = 94
• Patient Numbero Pressing 2 starts & pauseso Pressing 3 rewinds [you can then record over mistakes]o Pressing 5 ends dictation
Mandatory Inclusionso YOUR first and last nameo the first and last name of the attending
physician.o the first and last name of the patient.o the ENTIRE 10-DIGIT patient numbero Date of visito Diagnosis/Results/Procedureso the first and last name of physicians copies
need to be sent to.
The Art of La Dictee
o How about “good morning... And thank you” [you’re talking to a person not a computer]
o Spell out all names [and give specialties of MD’s]o Spell out all medical termso Spell medications, give the dose and regimeno GIVE PUNCTUATION “ begin new paragraph.
Period. Colon....&c.”o Visualise the note taking shape infront of you.
Questions?
Do’ not a be dictator bad