How to Verbally Dictate a Note
As a clinical clerk, one of the most important skills you'll need to develop is the ability to document your patient encounters accurately and efficiently.
While there are various methods of documentation available, some hospitals use verbal dictation as a way to record progress notes.
Here we’ll cover some tips on how to verbally dictate your note.
Here we’ll cover:
What is verbal dictation of a progress note?
How to get started with a verbal dictation
Dictation Instructions
Template of a Dictated Note
I. What is verbal dictation?
Verbal dictation involves speaking your note out loud and having it transcribed into a written document by a transcriptionist or using speech recognition software.
If the hospital uses a transcriptionist, this involves dialing into the transcription system, inputting your dictation ID, patient ID, service, and type of documentation, and then speaking your note out loud.
Why is verbal dictation still used?
Many hospitals in Canada have migrated to electronic medical record systems (e.g. EPIC) where you can type out your SOAP notes, use templates and go back and edit your dictations.
However some hospitals still use verbal dictation for progress notes. One benefit of using verbal dictation is that for some clinicians, dictation is faster than typing out the note. Rather than spending time typing out notes, clinical clerks can speak their notes aloud and have them transcribed, freeing up more time for patient care and other tasks.
Some of my PA colleagues find dictation faster, personally I find utilizing templates in EPIC and typing my notes faster. There are times when I use a combination of both typing and dictating certain aspects of my note faster.
Verbal Dictation involves Saying Punctuation and Sentence/Paragraph Formatting Outloud
Your verbal dictation will turn into the patient’s official progress note on their medical record.
Imagine someone is listening to your dictation and attempting to type out everything you say. If you did not state your punctuation, when a sentence ends and when you’re starting a new paragraph - your dictation which just be one huge run-on sentence that would be difficult to read and follow.
In a dictation you are saying punctuation and formating outloud.
For example, if I wanted my note to look like this:
HISTORY OF PRESENTING ILLNESS:
Jessica is a 12 year old female who presents joint pain and swelling affecting the knees, ankles, wrists and elbows. She also reports intermittent fever and malaise the past week. Her parents report swollen lymph nodes and a sore throat. There is occasional chest pain and shortness of breath on exertion. No recent injury or trauma. She has tried Aspirin with some pain relief.
Then I would dictate this (text in red is me reading outloud the punctuation into the dictation)
New Paragraph New Heading History of Presenting Illness Colon
Next Line Jessica is a 12 year old female who presents with joint pain and swelling affecting the knees comma ankles comma wrists and elbows period She also reports intermittent fever and malaise in the past week period Her parents report swollen lymph nodes and a sore throat comma There is occasional chest pain and shortness of breath on exertion period No recent injury or trauma period She has tried Aspirin spelt A-S-P-I-R-I-N with some pain relief period
II. How to Get Started with Verbal Dictation
Getting started with verbal dictation may seem daunting at first, but with some practice, it can become a valuable tool for documenting patient encounters.
Here are a few steps to help you get started:
Familiarize yourself with the dictation software: Before you start using verbal dictation, make sure you're familiar with the software or equipment you'll be using. You’ll have to ensure you have a login or an ID for the dictation software. If you have to dial in from a hospital phone into a dictation system, find the hospital instructions on how to do it. These instructions are usually provided at the start of your rotation.
Keep in mind the notes you make during a patient encounter will be used as reference when you are verbally dictating your note. You do not have to write out full sentences. For example when you write “Aspirin - some benefit”, you can verbally dictate “She has tried Aspirin with some benefit for her joint pain and swelling.” Your notes are there to prompt you to dictate full sentences.
Practice speaking your notes aloud: If this is your first time, practice speaking your notes aloud before you start recording them. It may feel unnatural to have to speak while including punctuation (“New Paragraph”, “New Heading” , “Colon”, “Period”, “Next Line”) and spelling out important terms like the patient first and last name, medication names in case this may be mis-transcribed. This will help you get used to the process and ensure that your notes are clear and easy to understand.
Use a template: Use a template to help guide your note-taking and dictation. This will ensure that you include all the necessary information in a clear and organized way. You can also ask to see examples of dictations other clincians on the services have used as a reference of how to organize and format your dictation. We'll provide you with a template for a SOAP note in the next section.
Make use of the pause and rewind function! I have definitely fumbled over my words when dictating from time to time, even as an experienced PA. Figure out which buttons are the “rewind” function (e.g. going back 3 or 5 seconds") so that you can record over a mistaken sentence or phrase, and “pause” and “resume” so you can briefly collect your thoughts before you start the next phrase. Otherwise if you don’t hit “pause” you will have long periods of silence during your dictation which is not good use of time for the transcriptionist.
Speak clearly and slowly: When speaking your notes aloud, make sure to speak clearly and slowly. This will help ensure that your notes are accurately transcribed.
Review your notes: After you've recorded your notes, review them to make sure they're complete and accurate. If you notice any errors, correct them before submitting your final note.
How long should dictating a note take?
The amount of time it takes to verbally dictate a note can vary depending on a number of factors, including the complexity of the patient's case and your level of experience with dictation. In general, however, a well-prepared and organized note should take no more than a few minutes to dictate.
The first time I tried my hand at a verbal dictation, it took me 30 minutes to dictate a note. I kept pausing to gather my thoughts and figure out the next sentence to say. I went back and had to re-dictate over a previous sentence or paragraph because I had forgotten an important point. As a fully practicing clinician, it takes me now less than 2 minutes to dictate a succinct and focused progress note.
It's important to remember that while verbal dictation can be a quick and efficient way to document your patient encounters, it's also important to take the time to ensure that all necessary information is captured accurately. Rushing through your note or omitting important details can lead to misunderstandings and potential medical errors.
If you find that you're consistently struggling to complete your notes within a reasonable amount of time, it may be helpful to review your preparation process and seek feedback from your preceptor or colleagues.
III. Dictation Instructions
Here is an example of instructions from a hospital on the digital dictation system:
Example of a Hospital Dictation Instruction Sheet:
X HOSPITAL DIGITAL DICTATION SYSTEM
Welcome to X hospital! Voice recognition is the current system we utilize for patient’s progress notes and reports. Do not share your dictation number. For clarity and to reduce blanks in dictation reports, please dictate on a land line and do not dictate while on speaker phone.
How to Dictate:
Dial extension 1234 when on site, or dial 123-345-6789 from any off-site location.
Enter your dictation ID (a 5 digit number), followed by the # sign.
Enter 1 to begin a new dication
Enter the patient’s Medical Record Number (MRN), followed by # sign
Select the Report Type, followed by # sign (see the list below):
1 = Consultation Note
2 = Operative Note
3 = Discharge Summary
4 = Clinic Note
To start dictating, enter 2, this will immediately start recording. Use the following commands during dictation if required:
1 = Pause Recording
2 = Resume Recording
3 = Rewind & Play: rewinds 4 seconds and resumes play
4 = Fast forward and Play: forward 5 seconds
5= Cancel & Continue: Erase current dictation and continue (1 to confirm, 0 to continue dictation)
6 = Rewind to Beginning and Play
7 = Forward to End and Play
8 - Save current dictation and start next dictation
To end your dictation, or dictate another report, enter 8.
The Content of your Dictation:
Identify yourself: Start your dictation by clearly starting your name, designation (Clinical Clerk), service and clinic, indicate the attending staff you are dictating for.
Identify the patient: State the patient’s full name clearly, spelling the first and last name. State patient’s medical record number, date of birth, visit number and dates of visit.
Identify who should be copied on the note: State/spell the name of the staff and provide an address or fax of the external health care provider receiving a copy of the note (e.g. the family physician)
Dictate your SOAP note: This should include the subjective, objective, assessment and plan. See further examples below!
IV. Template of a Dictation Note
a) What you would verbally dictate
If we want the final document to look like above, this is what we would verbally say out loud.
Text highlighted in blue indicates the information you have to state before and after your dictation.
Text highlighted in red indicates punctuation and formatting you would say out loud when dictation.
This is Jack Black, clinical clerk dictating for Dr. X, Orthopaedic Surgeon for a fracture clinic visit. This is for Jane Smith, MRN is 00000. DOB is September January 1, 20__. Visit number is [insert visit number]. Date of visit is [insert date of visit]. Copies to Family Physician Dr. Y, Fax number is 123-456-7890.
Start of Dictation
New Paragraph New Heading FRACTURE CLINIC CONSULT NOTE
New Paragraph New Heading PATIENT ID Colon
Next Line Jane Smith, 24F
New Paragraph New Heading REASON FOR REFERRAL Colon
Next LineLeft distal radius fracture
New Paragraph
Next Line To Dr. Y Colon
New Paragraph period
Jane is a pleasant 24 year old right hand dominant female seen at the fracture clinic today at X hospital for new consult regarding a left wrist injury period She was seen by Dr. X comma Orthopaedic Surgeon and myself comma [your name] comma clinical clerk period
New Paragraph New Heading HISTORY OF PRESENTING ILLNESS Colon
Next Line Jane reports 2 weeks ago on September 17, 20__ she had a slip and fall resulting in a FOOSH injury with wrist in extension period No head injury or loss of consciousness period [insert remainder of history including OPQRSTU, initial treatment, procedures in the ED, any associated symptoms] period
New Paragraph New Heading PAST MEDICAL HISTORY Colon
Next Line She is otherwise healthy period
New Paragraph New Heading MEDICATIONS Colon
Next Line 1 period Tylenol PRN
Next Line 2 period Ibuprofen PRN
New Paragraph New Heading ALLERGIES Colon
Next Line No known drug allergies period
New Paragraph New Heading SOCIAL HISTORY Colon
Next Line Jane is right hand dominant period She works in an office position period Non-Smoker period Non-Drinker period No recreational drug use period Enjoys knitting and crafting comma hiking and gardening period
New Paragraph New Heading PHYSICAL EXAMINATION Colon
Next Line On physical exam today, Jane is distally neurovascularly intact to mediancomma radial and ulnar nerve period [insert remainder of physical exam findings] period
New Paragraph New Heading IMAGING Colon
Next Line Left wrist x-rays Open Bracket September 30 Comma 202__ Closed Bracket demonstrate a non-displaced extra-articular transverse distal radius metaphyseal fracture period No shift in fracture fragments since previous radiographs period
New Paragraph New Heading ASSESSMENT Colon
Next Line Jane is a pleasant 54-year-old right-hand-dominant female who presents two weeks post-injury from left non-displaced extra-articular distal radius fracture period
New Paragraph New Heading PLAN Colon
Next Line We are going to proceed with non-operative management period Splint was removed without complications period She was outfitted with a fibreglass cast and gentle closed reduction. Post-reduction x-rays demonstrated she was in a good position period She is to remain non-weight bearing with the left arm period We will see her in 4 weeks time for new x-rays and cast removal period
End of Dictation
b) What the final dictated note would look
Once you’re done dictating, this is what the final version of the note would look like:
FRACTURE CLINIC CONSULT NOTE
PATIENT ID:
Jane Smith, 24F
MRN: 000000
DOB: January 1, 20__
REASON FOR REFERRAL:
Left distal radius fracture
To Dr. Y:
Jane is a pleasant 24 year old right hand dominant female seen at the fracture clinic today at X hospital for new consult regarding a left wrist injury. She was seen by Dr. X, Orthopaedic Surgeon and myself, [your name], clinical clerk.
HISTORY OF PRESENTING ILLNESS:
Jane reports 2 weeks ago on September 17, 20__ she had a slip and fall resulting in a FOOSH injury with wrist in extension. No head injury or loss of consciousness. [insert remainder of history including OPQRSTU, initial treatment, procedures in the ED, any associated symptoms].
PAST MEDICAL HISTORY:
She is otherwise healthy.
MEDICATIONS:
1. Tylenol PRN
2. Ibuprofen PRN.
ALLERGIES:
No known drug allergies.
SOCIAL HISTORY:
Jane is right hand dominant. She works in an office position. Non-Smoker. Non-Drinker. No recreational drug use. Enjoys knitting and crafting, hiking and gardening.
PHYSICAL EXAMINATION:
On physical exam today, Jane is distally neurovascularly intact to median, radial and ulnar nerve. [insert remainder of physical exam findings]
IMAGING:
Left wrist x-rays (September 30, 20__) demonstrate a non-displaced extra-articular transverse distal radius metaphyseal fracture. No shift in fracture fragments since previous radiographs
ASSESSMENT:
Jane is a pleasant 54-year-old right-hand-dominant female who presents two weeks post-injury from left non-displaced extra-articular distal radius fracture.
PLAN:
We are going to proceed with non-operative management. Splint was removed without complications. She was outfitted with a fibreglass cast and gentle closed reduction. Post-reduction x-rays demonstrated she was in a good position. She is to remain non-weightbearing with the left arm. We will see her in 4 weeks time for new x-rays and cast removal.
Final notes
By utilizing a structured template and speaking clearly and concisely, you can create accurate and effective progress notes that provide an efficient communication tool for your healthcare team. Take opportunities to practice during your clinical clerkship, and don't be afraid to seek feedback from your preceptor or colleagues!
