Most doctors wish they could spend less time documenting care and more time providing it. Dictating clinical notes in the presence of your patients is a win-win: you maximize efficiency and repeat the treatment plan to the patient.
Let’s review the benefits of mobile medical dictation and help you decide if real-time dictation is the right documentation workflow for your practice.
Mobile medical dictation provides unparalleled flexibility
Dictation is easier than ever in the digital era. Using modern voice recognition software, you can speak into your smartphone and have your words appear instantly in the patient chart. There is no dictaphone and no complicated software with a long learning period.
So why do many physicians still type notes?
Dictation is the obvious best choice from an efficiency perspective. Basic math reveals that dictating clinical notes is faster than typing them. However, as a physician, efficiency isn’t the only significant variable to you. You want to provide excellent care, connect with your patients, and keep a profitable practice. Making dictation work for you requires finding the correct workflow.
Mobile medical dictation creates new possibilities for how, where, and when you dictate. Using HIPPA-compliant speech-to-text 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.
While dictating anywhere is convenient, it pays to do your homework early. Nearly every provider knows the stress caused by completing notes at home when you should be relaxing or spending time with the family. Dictating clinical notes during patient visits helps you close charts during work hours and benefits patients.
Benefits of dictating clinical notes in the presence of your patients
Many doctors have realized the benefits of medical dictation as a substitute for typing clinical notes. However, a smaller subset has embraced the advantages of completing dictation during visits.
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 clinical notes in the exam room reduces the time spent 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 the fastest option.
You can save even more time by incorporating dictation into the patient visit. For example, rather than repeating care instructions to ensure the patient understands, begin dictating while recounting pertinent highlights. In this way, patient communication doubles as documentation time.
2. Higher quality care
Most family physicians see about 20 patients daily. If you delay documentation to later in the workday or late-night charting, it can be hard to remember all the details.
By dictating clinical notes during each visit, you capture essential information while the details remain fresh. By speaking this information, you also review it with the patient, who can correct any errors or add important information.
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 also improve the patient experience. Patients want to feel heard and understood, and by repeating your diagnosis and treatment plan in their presence, you demonstrate that you clearly understand their condition.
Of course, as with any other procedure, you should tell the patient what you’re doing. For example, you might say, “I’m going to dictate a few notes into your medical record to ensure we get everything right.”
Federal rules already give patients access to clinical notes, which means that your patients can read your notes anyway. You resolve any confusion or disagreement upfront by dictating your notes during the visit.
4. Decreased malpractice risk
Doctors who dictate clinical notes in the patient’s presence may unwittingly reduce their risk of malpractice claims. Reviewing notes with patients ensures that records are contemporaneous, patient-witnessed, and patient-approved. Charts are more likely to be complete and accurate when you invite patients to amend or correct the information as you document.
Some physicians who use this method include the phrase “dictated in the presence of the patient” in their notes. This inclusion provides powerful protection in case of any dispute.
Research also shows that improving patient communication for primary care physicians can decrease malpractice risk. 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 their understanding, and encouraging patients to talk).
Dictating during a visit creates numerous opportunities to practice effective clinical communication.
5. Better income
A medical record that mirrors the entire patient encounter warrants a higher-level evaluation and management code than one that only captures the details you can recall from memory. By completing documentation in real-time with supplemental information from the patient, you’re more likely to produce a complete and accurate note, resulting in improved reimbursement.
Also, consider the value of your time. Studies show that medical dictation speeds up documentation by over 30%, and time saved translates to a significant earnings difference. Even a small investment in mastering a new dictation workflow can pay substantial returns over time.
Ask your colleagues
Which of your fellow physicians uses medical dictation? Do any of them dictate 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 why he dictates clinical 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