The quality of documentation is highly reliant on the quality of the dictation and the skills of the person doing the dictation. Learning how to improve dictation skills is quite possibly one of the most important parts in the documentation process.
By adhering to the following tips and making sure you are using a high-quality dictation equipment, you can quickly improve the quality of your dictations.
Adopt a conversational tone and talk at a normal rate, so your dictation is audible. Depending on the microphone type, hold the dictation device about 3″ from your mouth. Additionally, it should be held in a vertical, straight position. Therefore, the voice does not directly go into the microphone; Instead, it goes over the top of it. Also, make sure that your hand does not cover up any part of the mic. Similarly, don’t move the device to attain greater clarity.
Don’t just begin immediately as the dictation starts. Take a brief pause before starting or stopping the recording. This prevents your words from getting clipped.
Provide Complete Details
While talking about a patient, it is advised that you spell out their full name, address, medical record number, and any other critical information.
Sometimes, two similar letters are heard alike. Especially when the listener can’t pick up the accent of the speaker. For instance, “S” and “F” are two letters that get mixed up. To make sure that the scribe can understand you, you can associate certain meanings to such letters. You may spell “S for Sacramento” or “F for Florida” to help your scribe. Additionally, don’t stress too much on “twentieth” or it might be heard as “twenty-eight”.
Select a Quiet Area
Your dictation can become a major fail if you record in areas with distractions such as ringing telephones, people talking, vacuums, music, etc. Sometimes, even a mere air conditioning noise can degrade the audio. Select an area that’s quiet. The use of lower quality microphones tend to pick up all kinds of noises. Hence, if you dictate in a peaceful, quiet environment, it cannot only bolster results, but help you in managing patient confidentiality.
Rewind and Erase Errors
Rewind and erase are any existing errors. Refrain from making errors and don’t speak something along the lines of “strike that”. Instead, utilize “cue and review”, a feature in the dictation device that allows you to remove your sentences. Such a deletion of errors also ensures that your scribe does not misunderstand your statements.
After your dictation ends, say “End of Dictation”. This can give a hint to the scribe that you no longer plans to continue with further statement and the audio file has ended.