Thursday, September 6, 2007

Garbled Messages

Doctors examine patients every day. Doctors dictate their findings on a regular basis. What could possibly go wrong such a straightforward situation?

Most doctors dictate information in a helter-skelter pattern which is, at best, exasperating. At its worst, it can be terribly confusing. While some doctors are very diligent about saying:

"Neck was supple, with full range of motion. Chest had good inspiratory/expiratory effort -- no rales, rhonchi, or wheezes. Abdomen was soft, nontender, with normal bowel sounds, no organomegaly."

Other physicians dictate in a stream-of-consciousness style which forces a transcriptionist to leapfrog around a template without always being sure that the right information is going in the right place. For example:

"Neck was supple, with full range of motion. Patient walks without difficulty. Oral mucosa dry. No edema. Limited range of motion. Normal bowel sounds. No adenopathy. Sensation intact. A few ecchymoses. Slight swelling. Intact strength in all extremities."

On the basis of what the physician dictated in the second quote, how is the transcriptionist supposed to determine:

Where does the patient have edema?

Where is the patient's sensation intact?

Where are the patient's ecchymoses?

Where does the patient have slight swelling?

Now ask yourself:

Whose job is it to answer those questions?

Next: How To Dictate Instructions For Special Formatting

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