Dictating your charts can be an effective way to write your
charts if you know what you are doing.
If you do not know what you are doing, your charts are
likely to be disorganized, rambling masses of words that your readers cannot
make sense of.
Depending on what your charting system allows, you may have
the option to dictate all or part of your chart.
A few key concepts will hold true regardless of whether
you dictate all or part of your chart:
- Dictate purposefully
- Spoken language is different than written language
- Keep your goal in mind
- Stay organized
- Use a few written notes
- Proofread
Some of these concepts are related and some build on each
other.
Dictate Purposefully
Becoming proficient at dictating can only come with
practice. Just reading this article or a similar one will not make you good at
dictating. You must practice dictating to become good at it.
However, dictating a lot without keeping certain
guidepost principles in mind will most likely not make you proficient, it will
instead help you develop bad habits.
This crash course will give you some guiding principles
to keep in mind as you dictate. If you use these principles purposefully when
you dictate, your dictations skills will improve quickly.
Spoken Language is Different Than Written Language
We can write the way we naturally talk. However, it is
not efficient. Think of written and spoken language as 2 different dialects of
the same language.
To dictate well, you should translate your spoken
language into written language.
Typically, spoken word relies on cadence, tone, rhythm,
and other nonverbal cues. Written word does not have these.
Spoken word put in writing is also longer because it often
depends on the passive voice and repetition. Written language needs fewer words
to convey the same idea because, the reader has the opportunity to re-read,
pause, and digest what you are trying to communicate.
Rules and tips for good writing are beyond the scope of
this crash course, but you can find these easily.
Keep Your Goal in Mind
Your goal is what you are trying to communicate. For
example: My patient has pneumonia and is
safe to go home or My patient has
pneumonia and is sick enough to be admitted.
This sounds basic. However, it is easy to lose your focus
and get off track when you are dictating.
One explanation for why you can lose track is that you
can talk more quickly than you can think. In essence, your mind cannot keep up
with your mouth. Contrast this with when you write. Writing is generally slower
than speaking and you have more time to process your thoughts.
Another explanation is that you can get lost in the
details of the chart. Losing the proverbial forest for the trees.
When dictating, slow down a bit and focus your dictating
on details that further your goal.
Stay Organized
It is easy to dictate a disorganized chart. So be mindful
to stay organized.
Written charting often has built in forms for you to fill
out. Depending on the medical record system you are using, you may or may not
have these.
If your system is more free text, you will have to make your own, mental template. For
such a template, have a standard, personalized order of how you will present
the information. For example, in a review of systems, you should try to present
organ systems in the same order every time. Your physical exam, and assessment
and plan should similarly have the same template.
Training yourself to use the same template increases the
chance of your chart being complete.
One trap you can fall into using the same template every
time is that you do not customize it to your patient. In these cases, you are
dictating out of reflex. This is the same trap you can fall into using written
templates. To minimize this, slow down when you dictate, and keep your goal in
mind.
Use Handwritten Notes
Handwritten notes are obviously a memory aid. However, having
a few, handwritten notes also can help focus your mind during dictation.
If you dictate your patient cases in batches, using notes
can be very effective in helping you remember the details. Your handwritten notes
should not be lengthy, but should contain a few key elements in your patient’s
case. Try to keep your handwritten notes focused on what makes this patient
unique.
Proofread
Once you are finished dictating your chart, read through
it and ask yourself, “Does this chart say what I want it to say?”. This is
universal advice for anytime you write something.
The most practical time to do this will probably be once
you finish dictating. However, you are likely to catch more mistakes if you
proofread later in the shift, even at the end. Your mind will approach the
chart with a more “fresh eyes”. This is analogous to someone writing an
article, coming back to it a couple days later, and making better self edits
than if they proofread immediately after they wrote the article. When your mind
has some distance away from the chart, you can take this outside perspective
more easily. Your mind is less likely to automatically fill in the gaps that
are in the story that is in your chart.
As mentioned earlier these are tools for you to use while
you dictate to help you become more proficient. Reading this alone cannot make
you proficient, you have to practice by dictating purposefully and
thoughtfully.
If you are interested in learning more about medical
documentation, you can also check out my book: The
Handbook of Medical Charting
