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