Thursday, September 6, 2007

Dictating Physician

Having rendered treatment to a patient, the dictating physician must document his findings and treatment in a timely and coherent manner. Webster's New World Dictionary defines a dictator as follows:

  • In ancient Rome, a magistrate with supreme authority, appointed in times of emergency.

  • A ruler with absolute power and authority, especially one who exercises it tyrannically.

  • A person who orders others about domineeringly, or one whose pronouncements on some subject are meant to be taken as the final word.

  • A person who dictates words for another to write down.

For the purpose of this learning experience (and the future of your medical career), it is recommended that you embrace only the fourth definition!

When dictating reports, it is the physician's responsibility to accurately include as many items regarding the patient's demographics (name, medical record number, room number, date of admission, date of discharge, etc.) as are required for each type of report.

The physician needs to be familiar with the types of reports he has to dictate, the proper codes for generating those reports, and the various styles or templates which are used within those reports. It is the physician's responsibility to enunciate clearly when dictating so that the person transcribing his work can understand the physician's dictation.

Whenever there is the slightest possibility of confusion, misinterpretation, or misspelling with regard to a patient's name, a pharmaceutical, or a referring physician's name, it is the dictating physician's responsibility to make sure that the transcriptionist has been provided with the proper spelling of the word(s) in question.

Next: Understanding The Process of Transmitting Information

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