Do you dictate your clinical notes? If not, have you thought about trying this approach to clinical documentation? What would it be like to dictate your notes during patient visits?
This article discusses choosing the right dictation workflow and why some physicians dictate clinical in the presence of their patients.
Mobile medical dictation creates new possibilities
Dictation is easier than ever in the digital era. Gone are the days of tape recorders and long delays waiting to receive transcriptions and close charts. Using modern voice recognition software you can speak into a microphone and have your words appear instantly in the patient chart.
So why do many physicians still type notes?
Dictation is the obvious best choice from an efficiency perspective. Basic math reveals that it’s faster to dictate clinical notes than to type them. But as a physician, efficiency isn’t the only variable that’s important to you. You want to provide great care, connect with your patients, and keep a profitable practice. Making dictation work for you requires finding the right workflow.
Mobile medical dictation creates new possibilities for how, where, and when you dictate. Using the latest speech recognition software you can use your smartphone as a universal dictaphone that instantly transcribes your words into any text field on any computer. You can even create dictations on the go, which remain securely stored on your mobile device for later transfer into the EMR.
At a time when doctors can dictate anywhere – at home, at the office, or on the commute – why dictate during patient visits?
5 reasons to dictate clinical notes in the presence of your patients
Dictation has lots of benefits as a way of capturing clinical data. But many argue that moving this documentation process to the exam room creates further value for patients and providers. There are at least five good reasons to adopt a documentation workflow that includes dictating in the presence of your patients.
1. More efficient documentation
Because we speak faster than we type, dictating in the exam room reduces time spend recording care. Most doctors type around 30 words per minute (WPM), while the average conversation rate for English speakers is about 150 WPM. Even accounting for pauses for dictation commands, careful word choice, and reflection, dictating is simply the faster option.
You can save even more time by incorporating dictation into the patient visit. For example, rather than repeating care instructions to make sure the patient understands, simply begin dictating while repeating pertinent highlights. In this way patient communication doubles as documentation time.
2. Higher quality care
Most family physicians see about 20 patients a day, and they’re expected to document a huge amount of information about each visit. If you delay documentation – whether to the end of the workday or to your nightly pajama time with the EMR – it can be hard to remember all the details.
By dictating during each visit you capture essential information while the details are still fresh. By speaking this information, you also review it with the patient who can correct any errors or add important details.
This collaborative approach involves the patient in a way that can improve compliance and ultimately the quality of care.
3. Improved patient satisfaction
Patient-present dictation can have the added benefit of improving the patient experience. Patients want to feel heard and understood, and by repeating your diagnosis and treatment plan in their presence you demonstrate a clear understanding of their condition.
Of course, you should tell the patient what you’re doing, as you would with any other procedure. For example, you might say “I’m going to dictate a few notes into your medical record to make sure we get everything right.”
As of 2021, a new federal rule requires that all providers give patients access to clinical notes, which means that your patients can read your note anyway. By dictating your note during the visit you ensure that any confusion or disagreement is taken care of upfront.
4. Foolproof malpractice protection
Doctors who document visits in the patient’s present may be unwittingly reducing their risk of malpractice claims. Reviewing notes with patients in this way ensures that records are contemporaneous, patient witnessed, and patient approved. Charts are more likely to be complete and accurate when patients are invited to amend or correct the information as it is produced.
Some physicians who use this method even include the phrase “dictated in the presence of the patient” in their note. This provides powerful protection in case of any dispute.
Research also shows that, for primary care physician, communication practices are associated with malpractice claims.
Communication behaviors associated with fewer malpractice claims include:
- statements of orientation (educating patients about what to expect and the flow of a visit),
- laughing and humor,
- and facilitation (soliciting patients opinions, checking understanding, and encouraging patients to talk).
Dictating during a visit creates numerous opportunities to practice effective clinical communication.
A medical record that mirrors the entire patient encounter often warrants a higher-level evaluation and management code than one that only captures the details you can recall from memory or basic notes. By completing documentation in real-time with supplemental information from the patient, you’re more likely to produce a full and accurate note, resulting in improved reimbursement.
Also, consider the value of your time. If dictating during visits ultimately speeds documentation by even 10-20%, that time savings equates to thousands of dollars a month. Even a small investment in mastering a new dictation workflow can pay substantial returns over time.
Ask your peers
Which of your fellow physicians uses medical dictation? Do any of them dictate clinical notes during patient visits?
Dr. Mark Casillas is an orthopedic surgeon in San Antonio who dictates using Mobius Conveyor, a premium medical dictation software that works on Mac and PC. Here’s how he describes his logic for dictating notes during patient visits:
“I like dictating the history, physical exam and my plan in front of the patient, because I can pause and ask them, ‘Is there anything I should have added or emphasized?’ They like to hear that I can dictate everything and for me it’s a matter of convenience that it’s all documented in the moment.”Dr. Mark Casillas, MD