What to Expect from a Physician’s Dictation

 

 

One thing that is important to know is what may be expected when transcribing a physician’s notes. Here is a scenario. The reader will find it is not as easy as it may sound. Again, listening skills with the ability to focus is essential.

The range of personalities when dictating are those that tend to be considerate: in example, Hello this is Doctor So and So. This is a 25 year old white male with BP 120/70 (make that a capital B and a capital P, the number 120 with a diagonal line over 70.)

With the first example, you’re bound to think that taking dictation will be a “piece of cake," however, the first example is the exception and not the rule. The next example falls more in line with the dictation you are likely to receive as a professional MT:

This is Doctor So and So with a letter, what date is this? Is it the 8th of January, no, make that the 9th, whatever, you check it. The letter is to look like the letter to M. Smith, somewhere in Sacramento, look it up, regarding the Henderson kid, I forget his name. Dear so and so, thank you for your referral of the most pleasant 42 year old female to me who was complaining of gastro-intestinal problems with no other associated problems. Then fill in the usual and so forth; normal exam; add the meds from the front of the chart, that will be good, signature, and so forth; copy going to Simpson in San Clemente. Next a letter to….

As you can see, should you be working in a physician’s office it will be necessary to acquaint yourself with systems; names, other than medical terms, continually paying close attention to details, as many of these physicians, in their busy workaday lives are too “hurried" and have their mind on patient diagnoses and other obligations to give an exact rundown as to what is needed. Therefore, it will not only be helpful for the MT to “pick up on the personality of the physician in regard to the following scenario, it will be equally important for the trained MT to know where to look for information whether it be in the confines of the office and the personal files of the patients or the proper medical related resources.

One thing that can be said, by attaining a strong medical vocabulary, the MT in his or her training will already be in the practice of focusing in on the details making sure to listen carefully as to not incorrectly comprehend the dictation of the physician or healthcare professional. Therefore keying in on other details as your career progresses will become second nature particularly after you have had plenty of practice listening and watching for inaccuracies.


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