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Best Practices in Dictation

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Best Practices in Dictation

Overview

Quality healthcare documentation begins with the dictation process.  When participants in the process work together, everyone benefits - the dictator, the medical transcriptionist, other healthcare professionals, and, most importantly, the patient.
 
The common problems are easily illustrated.  The dictator is often frustrated with blanks left in a report, the medical transcriptionist is perplexed when trying to decipher important passages obscured by background noises, the report is delayed in turnaround time as several quality assurance editors all try to decipher those same critical passages, the coder needs the report to initiate the reimbursement cycle and other healthcare professionals look at a report with blanks as risky to important decisions needed for patient care.
 
This white paper reviews the currently published standards and industry resources related to quality practices in dictation, the first step in quality healthcare documentation.
 
Solution
 
InfraWare Dictation Tips
 
Quality healthcare documentation begins with the dictation process! This Tip Sheet will assist you with creating a dictated message that promotes a quality healthcare document, patient privacy, prompt turnaround time, and improved communication between healthcare professionals.
 
  • Dictate only in designated areas offering a secure, quiet environment to avoid background noises, distractions, interruptions, and confidentiality issues.

  • Speakerphones and cordless phones should be avoided for acceptable recording quality.

  • Be aware of microphone placement and the proper use of functions such as Pause and Resume to avoid clipped words.

  • Correctly key in appropriate numbers when accessing the Telephone Dictation System to assure accurate identification of you, your healthcare facility, the patient, and the type of report.

  • At the beginning of each dictation, state your name and ID number, the patient name and number, type of report, dates, and any other special instructions. 

  • Spell the patient's name to affirm correct demographic data matching.

  • Perform dictation in a timely manner following each patient encounter and have all pertinent information available to avoid delays in documentation.

  • Use only facility-approved abbreviations within the dictation message and avoid the use of other abbreviations, jargon, slang, or acronyms.

  • When finished, indicate end of dictation.
InfraWare Dictation Standards and Best Practices
 
Clinical documentation and health records play a vital role in every aspect of healthcare delivery and decision making, no matter what the setting. Complete and accurate documentation is also a central focus in current efforts to improve healthcare quality and patient safety as well as the efficiency of the U.S. healthcare system.[1][1]
Quality healthcare documentation begins with the dictation process. There is no doubt that the complexity of the language of medicine, the dynamics of the healthcare environment, and the sophistication of the dictation systems today present a formidable challenge for dictating authors. However, the quality of transcribed documents is dependent in part on the quality of the dictated message.[2][2]
 
Two industry-related organizations (AAMT and ASTM) have published materials related to the importance of establishing a system for dictator feedback to promote quality improvement of the dictation process and the dictated message.
 
The American Association for Medical Transcription (AAMT) established standards with policies and procedures for quality assurance in medical transcription through the Metrics for Measuring Quality in Medical Transcription document. It states:
 
Quality in medical transcription voice-to-text conversion can be defined as clear, consistent, accurate and complete patient healthcare documentation derived from the dictator’s vocal communication. This quality is affected by the auditory quality of the voice being transcribed, by the education and skills of the dictator, and the education and experience of the medical transcriptionist (MT).

The QA process has a two-fold goal:

1)      Improved documentation through identification and explanation of errors.

2)      Improvement of dictator and transcriptionist skills through evaluation of error patterns found and follow-up educational efforts.[3][3]
 
The Metrics for Measuring Quality in Medical Transcription goes on to include:
 
Serious difficulties in transcription that result directly from the dictation should not be held against the transcriptionist (i.e. with negative point values) in a quality review. Rather, these should be indicators for further investigation of specific dictation flaws so that remedial action may be taken with the dictator. AAMT believes that because of the impact these flaws have on the ability to properly transcribe the dictation, there can be patient safety risks or a financial impact from unnecessary lawsuits emanating from patient safety risks or errors in document integrity, which could contribute to a negative outcome in any legal situation (i.e., a pattern of unprofessional behavior in a physician's documentation patterns).  Therefore, some method of reviewing and communicating these flaws should be part of the overall quality evaluation.
 
Finally, the Metrics for Measuring Quality in Medical Transcription defines:
 
Dictation Flaws: Specifically AAMT identifies the following: critical, major and minor as defined by patient safety and document integrity impact. It is crucially important to realize the impact auditory quality of dictation has on the transcribed document. Recognizing and documenting occurrences allows for identification of flaws and an opportunity for assisting dictators in their quest for patient safety and document integrity.[4][4]
 
ASTM International, which is an international ANSI-accredited standards-development organization with over 30,000 members, approved E2344: Standard Guide for Data Capture through the Dictation Process providing a guide that identifies ways to improve the quality of healthcare documentation through the dictation process.
 
A few of the key elements of this standard include:
 
  • Use only facility-approved abbreviations within the dictating message and avoid the use of other abbreviations, jargon, slang, acronyms, and/or coined terms. 

  • Maintain a quiet and secure area for the dictation process. Advise dictating authors to use the designated dictation areas to avoid background noises, distractions, interruptions and confidentiality issues. Advise dictating authors to avoid eating, gum chewing, yawning, smoking, etc., while dictating. Advise dictating authors to avoid side conversations and background distractions such as voices, telephone ringing, and/or music that may obscure the dictation. 

  • Advise dictating authors to avoid profanity and/or derogatory, and other inappropriate comments while dictating. 

  • Include the feedback system about the dictation process regarding any mechanical, technical, or other problems that may interfere with a clear, complete, and accurate document.[5][5]
 
More important elements of this standard state:
 
  • Use conversational speed and volume for optimal dictation message. 

  • Instruct dictating authors on the functions of the dictation system used within their healthcare environment. These include, but are not limited to, the following:

    • Use of the pause mechanism, use of the review mode, use of the insertion mode. 

    • Use of the types of phones used for dictating. Refrain from using speakerphones, portable phones, cell phones, and public phones. 

    • Use of microphone settings to avoid clipped words and phrases, proper distance of microphone and microphone element from mouth.[6][6]
It is significant to note that standards-development organizations, such as ASTM International, have “rules” to follow so that their standards are fair, relevant, and developed in a way that is objective and nonbiased. The American Nationals Standards Institute (ANSI) establishes these "rules" and organizations that follow them for developing standards are considered to have ANSI-accredited processes. 
 
ASTM standards are not mandatory, however, government regulators often give voluntary standards the force of the law by citing them in laws, regulations, and codes, as they are recognized as best practices within the industry. 
 
Healthcare institutions and vendors that incorporate ASTM standards in their processes enjoy the benefits of the work accomplished by the numerous volunteers who participate in the ASTM technical subcommittees. A few of those benefits include:
 
The AHDI Book of Style instructs medical transcriptionist’s to alert the dictator of the report with a "flag or notation" (this can be, of course, an electronic flag) to identify any dictation problems or inconsistencies within the dictation. It further addressed this issue by stating:
 
Medical transcriptionist’s play an important role in risk management through their commitment to quality in medical transcription and through their alertness to dictated information that indicates potential risk to the patient or the institution, including its personnel. When encountered, such information should be brought to the attention of the appropriate institutional personnel, as identified in the institution's program policies.[7][9]
 
Finally, InfraWare is committed to quality documentation and providing our clients with quality customer service. As a first step in this process, a dictation tip sheet will be provided to you. Please post this in appropriate locations within your institution where dictation is frequently performed, and provide a copy to all of those who have dictating privileges.


[1][1]Documentation for Acute Care. 2004. AHIMA.
[1][2]ASTM E2344-04: Standard Guide for Data Capture through the Dictation Process. ASTM International.
[3][3]Metrics for Measuring Quality in Medical Transcription. 2005. AAMT.
[4][4]Ibid.
[5][5]ASTM E2344: Standard Guide for Data Capture through the Dictation Process. 2004. ASTM International. 
[6][6]Ibid.
[7][9]AAMT Book of Style, 2nd edition. AAMT.


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Last Updated
Friday, March 31, 2017

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Dictation, Dictation Tips, Better Dictation KB67
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