Recently, someone asked me for pointers to improve
dictation. I realized that dictation was probably a less common now that in
years past, and many new graduates had little or no experience with this skill.
I made a list of pointers based on research I’d done for my
book, my previous blog post regarding written vs spoken English, my own
experience dictating charts, and years of watching my mother dictate the charts
she used to bring home from the office. I’ve summarized these points into this
brief blog post.
The underlying concept to keep in mind as you dictate is
that written
English is not spoken English. You should not dictate your chart in the way
you would speak. If you write the way you speak, your chart will typically be a
lot less clear and a lot longer than if you wrote it.
Remember that you want your reader to understand your story
quickly and easily. A long, rambling, unfocused chart does no one any good.
Well-thought out dictation can be just as good as a well-written chart at
conveying the patient’s story efficiently.
Keeping these few points in mind will bring you a long way:
- · Take a moment before you begin to organize your thoughts.
- · Have a template ready in your mind if you have enough similar cas
- · Have a few notes in front of you to focus your dictation.
- · Use short, simple sentences whenever possible.
- · Put related thoughts together into paragraphs.
- · Avoid needless repetition.
If you’re interested in learning more about medical charting
for clear communication, check out my book: The
Handbook of Medical Charting
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