Tips for Dictating Your Chart

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

Should I Make My Chart Vague?

Too many times, I’ve heard my colleagues say, “I leave my chart intentionally vague so that no one can find anything wrong with it” or “I make my charts generic so that when I defend it the way I want to”.

These strategies can actually their authors open to the very assaults these strategies are supposed to protect them from.

Your chart is a record of your vision of that patient, of your side of the patient’s story. The record should stand apart from you. It should speak for itself. A well-written chart explaining the patient’s story should not need you to translate it. Ideally from reading your chart, your reader should see the patient as you saw the patient. Your reader should see the patient so clearly that they agree with you. The ideal happens rarely, but we should always try to improve.

Here are 3 fictional examples of how being too vague can potentially get you into trouble.

The drunk:

Your intoxicated patient is now clinically sober. You discharge him. He trips in front of the hospital and a bus runs him over. At autopsy his ethanol level is 200. Two versions of your re-assessment are below:

Vague: Clinically sober now.

Specific: Clear speech. Oriented x3. Cooperative. Calm. Finger to nose normal bilaterally. Walks tandem gait without stumbling.

When someone reviews the case later, do you want your chart to read vague or specific?

The fracture:

A patient comes into the ER for right leg pain. She is a nursing home patient with dementia. Your clinical evaluation finds no acute pathology. You discharge her. 1 week later she comes in for leg pain again. Evaluation finds a fractured, right femur.

A nursing home assessment from before her initial visit to you reads: “Contracted, thin extremities bilaterally. Hyperpigmented rash at bilateral ankles.”

Two versions of your initial exam are below:

Vague: Bilateral lower extremities normal.

Specific: Bilateral lower extremities have no bony point tenderness, no swelling, no bruising, no deformity.

When someone reviews your chart later, do you want your chart to be vague or specific?

The stroke:

A middle-aged patient comes in for dizziness. You find no concerning findings on your evaluation. 2 weeks later, outpatient workup reveals a posterior circulation stroke. Again, two versions of your exam are below:

Vague: normal neurological exam.

Specific: Walks on tip toes without stumbling. Negative Romberg. No nystagmus.

When someone reviews your chart later, which way do you want your chart to read, vague or specific?

Certainly we could all go into painful detail about every last detail. But consider:

What are the important parts of the story we want the chart to convey?

What details tell our patient’s story and which are needless?

If you chart with specific and concreter details, your chart will better protect you whether it’s from a patient complaint, a morbidity and mortality conference, or a legal proceeding.

Your chart should stand on its own. You should build it well to protect you. You should not have to protect it.

If you’re interested in learning more about improving your medical charting, check out my book: The Handbook of Medical Charting.

Spoken vs Written English - The Writing Exercise

This post is another writing exercise. We’ll be applying lessons I’ve shown you from previous posts (Omit Needless Words, Pay Attention to Your Formatting, and Written vs Spoken English) to a sample, fictional chart.

This post should be helpful to those who either use voice to text software or scribes who tend to transcribe verbatim.

Follow instructions as with the previous writing exercise posts:

1.       Copy and paste the sample to a word processor.

2.       Make your edits using the writing principles.

3.       Compare your answer to the possible answer at the bottom of the post.

I wrote the sample history of presenting illness as if I was dictating verbatim into a microphone. Here it is:

The patient is a 28 year old male with a history of obesity and asthma. He comes in today via EMS after a motor vehicle accident. He was the restrained driver in a motor vehicle accident where he rear ended the other car at what he estimated to be 15-20 miles per hour. He denied LOC. He denied head strike. He denied memory difficulty. He denied drug or alcohol use in the past 24 hours. He denied chest pain. He denied extremity pain. He denied dizziness. He said that he was distracted for a moment returning a text when the accident happened. He said the front end of his car “was totaled”. He said he was able to walk afterwards. EMS report confirms that he was ambulatory at the scene. EMS report also confirms extensive damage to the front of his car.

This may work well for spoke English, but it’s poor written English. It’s a jumble that we can clean up with a little bit of work.

Work on it and then scroll down. I've shown you one path (certainly others exist) to a more efficiently-written version of this HPI. 

First, let’s pare the HPI down to essential words. I’ll highlight what’s (arguably) needless. Repetition is an easy first target for cutting out needless words. What words does the story need to drive itself forward?

The patient is a 28 year old male with a history of obesity and asthma. He comes in today via EMS after a motor vehicle accident. He was the restrained driver in a motor vehicle accident where he rear ended the other car at what he estimated to be 15-20 miles per hour. He denied LOC. He denied head strike. He denied memory difficulty. He denied drug or alcohol use in the past 24 hours. He denied chest pain. He denied extremity pain. He denied dizziness. He said that he was distracted for a moment returning a text when the accident happened. He said the front end of his car “was totaled”. He said he was able to walk afterwards. EMS report confirms that he was ambulatory at the scene. EMS report also confirms extensive damage to the front of his car.

 

 Now with some needless words taken out:

A 28 year old male with a history of obesity and asthma comes in via EMS after a motor vehicle accident. He was the restrained driver where he rear ended the other car at what he estimated to be 15-20 miles per hour. He denied LOC, head strike, memory difficulty, drug or alcohol use in the past 24 hours, chest pain, extremity pain, dizziness. He was distracted for a moment returning a text when the accident happened. He said the front end of his car “was totaled”. He was able to walk afterwards. EMS report confirms that he was ambulatory at the scene and extensive damage to the front of his car.

 

We’ve tightened our HPI up a little bit. Now let’s format it by separating out some logical sections.

One section could be a chief complaint with a little bit of context. Another section could be a review of pertinent systems. Yet another section could be confirmatory information from EMS.

I’ll highlight them in different colors and then separate them.

A 28 year old male with a history of obesity and asthma comes in via EMS after a motor vehicle accident. He was the restrained driver where he rear ended the other car at what he estimated to be 15-20 miles per hour. He denied LOC, head strike, memory difficulty, drug or alcohol use in the past 24 hours, chest pain, extremity pain, dizziness. He was distracted for a moment returning a text when the accident happened. He said the front end of his car “was totaled”. He was able to walk afterwards. EMS report confirms that he was ambulatory at the scene and extensive damage to the front of his car.

Our answer:

A 28 year old male with a history of obesity and asthma comes in via EMS after a motor vehicle accident. He was the restrained driver where he rear ended the other car at what he estimated to be 15-20 miles per hour. He was distracted for a moment returning a text when the accident happened. He said the front end of his car “was totaled”.

He denied LOC, head strike, memory difficulty, drug or alcohol use in the past 24 hours, chest pain, extremity pain, dizziness. He was able to walk afterwards.

EMS report confirms that he was ambulatory at the scene and extensive damage to the front of his car.

Now it’s much easier to read.

Are there other ways to separate and organize the information? Yes, but this is just to demonstrate the process. Each person will use these tools a little bit differently.

The important concepts to remember are to omit the needless words and to organize your thoughts in a logical manner on the screen.

To learn more about clear and effective communication in medical charting, please check out my book: The Handbook of Medical Charting