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Clear Dictation
A clear dictation style is probably the most important part of medical transcription, and yet it is the most overlooked aspect in medical-legal affairs. What you actually say is what gets transcribed most of the time. It can make you look good or not-so-good to those who read it, especially in a court of law. In addition, errors can be made with various fine points such as "no" or "not" when not heard clearly, etc. So to make your medical record as accurate as possible, clarity is most important.
What clear
dictation is
NOT:
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Just talking as you would to a patient or colleague |
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Using slang or “hip” English |
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Speaking into the recorder in the presence of background noise such as a vacuum cleaner or |
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in a noisy
office |
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Speaking too close or too far from the recorder’s microphone
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Not thinking through what you want to say first |
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Jumping from one thing to another in random order |
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Slurred speech |
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Poorly articulated phrases |
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Speaking too rapidly, especially when using very technical language
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The use of poor dictation equipment |
The best dictation includes:
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Use of high-quality digital recorders |
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Thinking through what you want to say before you start |
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Using notes and a dictation flow sheet |
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Using as clear a voice as possible |
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Over-articulating key words, especially names of drugs, people, places, diagnostic tests, |
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procedures, and other technical terms |
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Spelling out new words, especially new drug names or places that might not be familiar to an |
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outsider |
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Keeping speed in line with production of clear and articulated speech |
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