Partial Dictation

Partial Dictation: A Bliss

Free-text narrative will often be superior to a point-and-click boilerplate in accurately capturing a patient’s history and making assessments. Notes should be designed to include patient’s discussions of uncertainties.

Healthcare facilities are advancing towards Electronic Health Record (EHR) and Meaningful Use goals. Clinical documentation via narrative notes may change to a great extent. When it comes to the area of clinical documentation, the jury seems to be still out on which modality is best; most cost effective, most time-effective, best for overall patient care.

According to a recent EHR study, point-and-click takes about 4.5 minutes to generate a simple note; whereas with dictation, it takes only 1.5 minutes to generate the same note. Plus, EHR processes tend to alter the provider’s exam room interaction with patients to unacceptable levels.

What is the solution utilizing an EHR system and still maintain physician-to-patient contact while completing patients’ notes for Meaningful Use?

The partial dictation technique allows healthcare providers to use functionality within an EHR to generate some sections of the patient note while dictating other sections. These note fragments or partial dictations are then sent for transcription. Upon completion, the transcribed notes populate the patient’s electronic chart through a seamless interface in the way of discrete reportable transcription (DRT).

With most of the patient note entered via EHR templates, the amount of audio that goes to transcription is greatly reduced. This in turn reduces transcription costs. At the same time, physicians are given the option to dictate critical aspects of the encounter, which allows them to do it more quickly and with greater detail. The end result would be a hybrid model that combines the power of the EHR with the time and cost efficiency of dictation.