Techniques to use during medical dictation and recording

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Have you faced a scenario where you wanted to record a patient data, with maximum clarity and sound quality, but never got the desired result? As a physician or medical facility, you realize that clarity of the dictation is very important, especially as it greatly contributes to the accuracy of the transcribed medical record. If the recording is not clear, then even a certified medical transcription service company will find it difficult to convert the records and might end up wasting too much time and effort in deciphering the spoken words. Also yet there is no guarantee the records will be accurate, and in fact the quality rating of most transcription companies highly depends on the sound quality of the audio files.

03Here are few recording tips you can use while recording an audio file for medical transcription-

Surrounding noises: try to choose an area with lesser surrounding noises, especially as microphones can easily pick up noises. Dictating in a quiet and secure environment will significantly improve results and also maintain patient confidentiality. It is best to not record in areas prone to background noise and distractions such as – others talking, ringing telephones, music, vacuums, other speakers, beepers, etc.  At times even noises like air conditioning can be multiplied in the background and obscure the intended dictation. In case you at times may have no option but to dictate in an outdoor location, then try avoiding areas with – lot of traffic noises, very windy areas, etc. which can compromise the audio quality.

Speak clearly and into the microphone: it is important to talk in a conversational tone at a normal rate, so that the dictation is clearly audible to the transcriptionists, who need to provide quality records. Also depending on the microphone, the recorder needs to be held about 3/4″ from the mouth in an upright, level position so that sound goes over the top of the microphone and not directly into it. In case you are using a smart phone or tablet then it is important to know where the mic is to ensure you are not covering it with your hand while recording. Also avoid moving the recorder to get more clarity. Generally external microphones over built-in microphones provide better sound quality

Speak only one at a time: brief your team members about the digital audio recording and if they too are going to participate in the recording. Also request them to speak only one at a time, in a clear voice, and slow rate of speech. Also you may need to ask them to avoid speaking with each other during the recording or avoid other noises such as cell phones, etc.

Conduct a test: before sending the recording to the transcriptionist, initially it is best to first conduct a small test of your own recording. Talk few sentences and then check the sound levels, and quality of recording. This will give you an overall idea of the audio quality and your speech level, as well make you aware of any disturbing background noises which need to be removed.

Dictate & save immediately: it is best to dictate right after your patient encounter, so that the information is fresh in your mind and most probably more complete. Also after you have completed the recording, make sure that the data is safe by transferring the files either to your computer or if possible, to the transcription service immediately. Further backup files on a USB drive, as an added measure of securing important patient data.

Pause during unavoidable distraction: at times you may be called into another conversation which is important and cannot avoid. Or for any other unavoidable temporary interruption, it is best to stop recording and hit the “pause button” on your recording device. Only return to your dictation when you are no longer distracted.

Be careful of difficult terminology: Medical terminology can be difficult for transcriptionists to decipher at times. Take note of unusual or difficult terms, drugs, similar sounding words, and names of referring physicians. If you feel there can be any chance of confusion, then it is better to just spell out the word. While most certified medical transcription service, hiring competent transcriptionist will generally double-check spelling, but yet they should not have to guess your intended meaning. Sometimes not being able to transcribe the words they end up leaving blanks in the transcript, which results in extra turnaround time, staff, and costs utilized in getting the document completed.

Finally it is best to use well-qualified transcriptionists who can successfully understand a wide spectrum of accents and dictations to a certain degree. To evaluate whether your accent will be understood by the transcription service, you could first submit a sample dictation as a test. Physicians today are highly concerned about the accuracy of transcribed reports, especially as mistakes can cause considerably severe legal and financial impact. As this depends on the dictation, try as much as possible to record an audio file that has no background noise, a single person speaking at a time, and all the speakers evenly heard.

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