3 Proven Ways to Improve Your Medical Dictation

Feeling overwhelmed by the amount of time it takes to complete your progress note or H&P? You are not alone. Medical transcription software can help.

This article does not list every strategy under the sun, instead it lists the tactics that we use at StatNote. These are tactics that have helped us finish our notes in one-third of the time it usually takes.

At StatNote, we are famous for our dot phrases and templates, and we encourage every clinician to have their own set of smart phrases for the most common conditions they see in their practice. Using macros can save you time by avoiding repetitive typing. They are also very useful as point-of-care evidence based decision-making tools. In other words, they can remind you of guidelines to follow, labs to order, or treatment options to consider.

While using auto texts and snippets might be the most efficient way to complete your medical documentation, not every patient presentation fits the mold. Those complex cases, like a sick patient being admitted from the emergency department or a transition of care visit at the clinic after a prolonged hospitalization, are key examples. These hospital follow-up encounters can be challenging to document; there is a lot of information that might not be readily available, and we need to dig into the chart to find all the useful details.

For these cases, dictating your note might be a better option to document all your findings. Documenting using a medical speech-recognition solution is three to four times faster than typing them. Roughly 130 WPM (words per minute) versus 35 WPM, which is the average for a doctor.

When using speech-to-text for medical documentation, there are many factors that affect the quality of your transcribed note. Below are a few fundamental components:

  1. Verbal communication skills
  2. Audio quality
  3. Quality of voice-recognition software

1. Verbal communication skills

Some clinicians are better than others at narrating the clinical story. Dictating a note is an art in itself. For novice clinicians, it is very common to feel awkward talking aloud to a microphone, especially when surrounded by peers. You can easily become self-conscious. Millennials and younger generations are used to talking to Alexa, Siri or Google. For them, dictating instead of typing is less of a novelty and rather an every-day occurrence.

However, medical dictation can be challenging even for avid users of smart speakers and virtual assistants. It requires the clinician’s ability to organize her thoughts and articulate them in a fluent manner. Don’t get discouraged if you are initially having trouble organizing and articulating your thoughts. Practice makes perfect.

One tip to enhance your dictating is jotting down notes or keywords in advance to help you organize your thoughts during dictation. For example, when precharting or talking to the patient you can write small notes of important information you want to make sure you include in your note. This will help you to have a better narrative.

2. Audio quality

Audio quality is also important, as it can impact the accuracy of your documentation. Many factors can affect audio quality; let’s divide them in technical and functional factors. Technical factors include internet speed, equipment used for audio input (i.e., a dedicated microphone or headset vs a mobile phone app). Functional factors are either user-dependent or ambient-dependent. Examples of user-dependent factors are speech speed, articulation, volume or having a thick accent; these elements are inherent to each clinician. Ambient or external factors include background noise.

Mobility and portability are very important for most clinicians. In the outpatient clinical setting healthcare professionals move from room to room to see their patients, while in the hospital, patients tend to be even more dispersed. Invariably, they all usually work on more than one computer station. Being able to dictate using a dedicated headset or microphone is optimal.

This USB desktop gooseneck microphone frees up your hands to type, write or move your mouse. A StatNote favorite.

When dedicated audio devices are not available at every single computer work station, having a mobile application on your cell phone that works as a microphone is very convenient. Just ensure that internet speed is optimal, and avoid interruptions from notifications or calls. This will help you have a better experience while dictating.

Medical voice-recognition mobile app.
Silence notifications to avoid disruptions in your dictation.

Regardless of the type of device you decide to use for audio input, keep your microphone or audio device four to six inches away from your mouth. This can make all the difference in the world.

Choosing a dictation location that is quiet will not only ensure a better transcription quality, but also enhance security by avoiding unintended sharing of information, ensuring HIPAA compliance. Avoid background noise from conversations, music, or ringing phones. Another related functional factor is the volume. Sometimes clinicians, out of respect or self-consciousness, decrease their voice volume to avoid being overheard.

Try this, say out loud slowly and clearly the following phrase: “enunciate, articulate, exaggerate.” Do it a few more times to train your mouth muscles and speak clearly. Once you master articulation and volume, pay attention to your speech speed. Speak at a conversational rate.

Although some medical voice-recognition softwares transcribe conversational audio and automatically add punctuation and formatting, we find that the solutions that require punctuation commands have better accuracy. If you are using one of these programs, make sure you pause before using a punctuation command like “comma” or “period”.

3. Quality of voice-recognition software

Although Siri and Google have great accuracy when it comes to speech recognition, they don’t have a medical vocabulary. Google voice typing has gotten better at recognizing medical terms, but it’s not a replacement for a dedicated medical dictation solution like Dragon Medical Speech Recognition from Nuance or 3M M*Modal Fluency Direct.

Nuance’s technology is used in more than three-quarters of U.S. hospitals and by more than half of physicians in the U.S. But what if your organization does not offer this voice recognition technology? What are your options?

Chartnote is partnering with Augnito to provide the next generation voice artificial intelligence (AI) with best-in-class accuracy. Chartnote offers the best of both worlds when it comes to completing your medical documentation. On one hand, you have thousands of dot phrases and templates for those repetitive patient presentations. On the other hand, you are able to dictate your note when those patients have a higher complexity and don’t fix the box.

Chartnote is a perfect EHR companion to fight burnout by lessening the medical documentation burden. Check it out for yourself – create a free account today at chartnote.com.

Discover Chartnote – We are passionate about preventing physician burnout by decreasing the burden of medical documentation.

About Chartnote

Chartnote is revolutionizing medical documentation one note at a time by making voice-recognition and thousands of templates available to any clinician. We know first-hand that completing notes while treating patients is time-consuming and an epic challenge. Chartnote was developed as a complementary EHR solution to write your SOAP notes faster. Focus on what matters most. Sign up for a free account: chartnote.com

Posted on: April 26, 2021, by :

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