Dictation resources

[Abyssinia]

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Anyone know of any resources on learning how to dictate? This is my first time and I'm not sure if I'm doing it right...although I'm using the records from previous visit as a cheat sheet.

 

[bcmitch]

Anyone know of any resources on learning how to dictate? This is my first time and I'm not sure if I'm doing it right...although I'm using the records from previous visit as a cheat sheet.

It's the same as writing a note or H&P or whatever, except someone else is writing it down. This is my first month having experience with dicataion. I am with a private family physician, and I dictate all hospital admission H&Ps. For the first several, I would type the H&P out myself, get it just like I want it, then just dictate that verbatim. Now I'm starting to get better at organizing my thoughts so I can skip the writing it out part, though I do a lot of pressing the pause button while I think of what to say next.

So, there's nothing magic about it; it's just about generating notes on the fly. It takes some practice.

 

[THP]

I'm only a 3rd year so take my advice with a grain of salt. I have dictated several H&Ps before and I suggest using your maxwell's guide. (there is a section for dictation note. It will help you remember all the pertinent positives and negatives for the ROS and PE.

 

[DRDARIA]

Talk to the residents at your hospital, and see if some have a "cheat sheet" format they use for your specific hospital. The ones at my hospital did, and it was very helpful. Failing that, the Maxwell guide is a good, as the previous poster suggested.

Don't worry about feeling awkward. Dictating takes time to get comfortable with.

 

[Abyssinia]

Thanks so much!