Do you ever wish you could spend less time charting or documenting patient care in the EHR? This article will help you choose the correct medical dictation workflow and understand why some physicians dictate clinical notes 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 waiting hours to receive transcriptions and close charts. Using modern voice recognition software, you can speak into your smartphone 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 dictating clinical notes is faster than typing them. But as a physician, efficiency isn’t the only variable important 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 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.
When doctors can dictate anywhere – at home, at the office, or on the commute – why dictate during patient visits?
Five 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 additional 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 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 and have to document a massive amount of information about each visit. If you delay documentation to later in the workday or late-night charting, it can be hard to remember all the details.
By dictating 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 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 that you clearly understand their condition.
Of course, you should tell the patient what you’re doing, as with any other procedure. For example, you might say, “I’m going to dictate a few notes into your medical record to ensure 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 notes anyway. By dictating your notes 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 presence may be unwittingly reducing 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, for primary care physicians, 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 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. If dictating during visits ultimately speeds up documentation by 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 colleagues
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
