May
16
Written by:
admin
Friday, May 16, 2008
Several people have been interested in the techniques I use for dictating notes.
I have been using voice dictation for several years.
I first became interested in voice dictation several years ago.
In 2004 I began using Dragon dictation. At the time I think it was version 6, and computers were just becoming fast enough to cope with the program.
From version 7, I've use Dragon Dictation regularly for dictating patient notes.
Currently at version nine, the package is quite stable. I find it much faster to dictate notes than type.
Generally, dictated are vastly superior in depth and quality to either typed notes all scrawled handwritten notes.
I am voice dictating most of the updates and stories on this website.
With approximately 95% accuracy, voice dictation is reality.
Voice dictation requires a fast computer.
I often dictate, non-stop, several paragraphs with the program lagging several sentences behind me. This is probably a reflection of the fact that I have ~ a thousand entries for custom words and macros.
In order to achieve high recognition accuracy is necessary to have a good noise cancelling microphone. I use an Andrea USB NC-7100, ($149) . High accuracy requires a relatively quiet consultation room. You must learn to dictate your notes after the patient has left the room.
In addition to dictating the notes into medical director, I often print the notes out and paste them into our paper files. Alternatively I write a short note "see medical director" to represent the fact that I have written dictated notes into medical director.
I have several macros which insert standard consultation I have several macros which insert standard consultation templates. For example "insert adult URTI" inserts the following text
History: The patient presents with symptoms of rhinorrhea and infrequent dry cough over the previous three days. General health remains well. There is no sputum. There is no fever. There is no shortness of breath. There is no chest pain.
Systems review is otherwise NAD.
Examination: The patient appears well. Afebrile - Temp °C. Examination of the ears shows bilateral normal eardrums. Examination of the throat shows mild erythema of the tonsillar region.
Respiratory Examination is NAD. No creps. No rhonchi. No respiratory distress. There is no rash.
Reason for visit: URTI
Management: I have advised symptomatic management with paracetamol/ibuprofen/cold and flu tablets.
Review: PRN if deteriorating