How to Dictate Consult Note

Nadim Lalani MD

Who took dictation in school?

Dictation

o the transcription of spoken text: • one person speaks while the other writes down the

words as they are spoken.o la dictée : a school exercise aimed at testing the

mastery of orthography and grammar. o Some countries (e.g. France) hold dictation

championships.o Call the 1-800 number for your Dell and imagine

having to transcribe what that person is saying!

Why Bother?

o Patient Safety [esp when changing regimen]o Improved patient careo Improved relations with colleagueso Feedback to consulting colleagueo If you’re billing a consult you should be doing

this.o Essentially a reflection of your

professionalism.

ABC’s of a Dictationo Dial 944-4444 [or local 44444]o [British]computer will prompt you for

• Your College ID [basically your Alberta License # with no letter]• Work type

o 34 = emerg assessment• Site Identifier

o ACH = 91o FMC =92o PLC = 93o RGH = 94

• Patient Numbero Pressing 2 starts & pauseso Pressing 3 rewinds [you can then record over mistakes]o Pressing 5 ends dictation

Mandatory Inclusions

o YOUR first and last nameo the first and last name of the attending

physician.o the first and last name of the patient.o the ENTIRE 10-DIGIT patient numbero Date of visito Diagnosis/Results/Procedureso the first and last name of physicians copies

need to be sent to.

The Art of La Dictee

o How about “good morning... And thank you” [you’re talking to a person not a computer]

o Spell out all names [and give specialties of MD’s]o Spell out all medical termso Spell medications, give the dose and regimeno GIVE PUNCTUATION “ begin new paragraph.

Period. Colon....&c.”o Visualise the note taking shape infront of you.

Questions?

Do’ not a be dictator bad