Once you have formed a rough picture in your mind of how to structure the data you will dictate, you can begin to speak. As you dictate each report, try to visualize a train moving through a tunnel.
- Remember that the first part of the train to enter the tunnel is the engine. The "engine" of the report contains the report heading, patient demographics, information about who else should receive copies of the report, and the date of the report.
- The second part of the train to enter the tunnel is the mail car. The "mail car" contains the opening parts of the report (admitting diagnoses, reason for admission, basic operative information, etc).
- The third part of the train to enter the tunnel is the part which contains the passenger and dining cars. These cars contain the information found in the patient's history of present illness, past history, review of systems, physical examination, hospital course, laboratory data, etc.
- The last part of the train to enter the tunnel is the caboose, which contains the discharge diagnoses, prognosis, discharge medications, discharge plan, instructions for activities, diet, followup, signature block, etc.
When you finish dictating a report, ask yourself:
- Did everyone on the train of patient documentation enter the tunnel safely?
- Did they come out the other end in one piece?
- Or is your train going to stay stuck in the tunnel because of an informational
breakdown?
Remember: You don't want a reputation for train wrecks that rivals Amtrak's!
Next: Developing A Rhythm
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