A template is where you decide once what your report looks like. What is in the template, you do not have to say every time. What is not in the template is left for dictation. That is why it pays to prepare the template before the first dictation instead of fixing it along the way.
This article walks through the five decisions you make while doing so: sections, order, fixed phrases, writing style instructions, and the choice between your own Word template and a template by specialty.
What the template does in AiMED Dictate
You choose the template before you dictate. The text you dictate goes into the sections of the template you chose. A template consists of named sections, their order and writing style instructions.
The template knows nothing about the patient. It sets the shape of the report, and the content comes from what you say.
1. Start from the reports you already write
Take a few of your reports of the same kind, without patient data, and put them side by side. The headings that repeat in every one of them are your sections. The sentences that repeat word for word are candidates for fixed phrases. Everything else is dictation.
This step matters more than any setting. A template that follows the way you actually write is easier to use than one that looks tidy but does not resemble your reports.
2. Sections: as many as you really fill in
Give each section the name you already use in the report. For an abdominal ultrasound that could be Indication, Findings and Conclusion. For a general examination it could be History, Status, Diagnosis, Therapy and Recommendations.
Two practical rules:
- A section you fill in only now and then does not belong in the basic template. Make a separate template for that kind of examination.
- If you always write two sections together, merge them into one. Fewer sections means fewer places where text can end up in the wrong spot.
3. Order: the way the report is read
Arrange the sections in the order a colleague should read them. You can change the order of sections in a template, so feel free to correct it once you see the first reports.
While dictating, it helps to say the name of the section you are moving to, for example: “Indication, pain under the right costal margin. Conclusion, normal abdominal ultrasound.” That way it is clear to you, and to anyone who reads the report later, where each sentence belongs.
4. Fixed phrases: in the template, not in the dictation
You can enter fixed text in a template section, with fields that are filled in from the dictation. This is the place for whatever always reads the same in your reports: the description of the examination technique, standard notes, the usual opening line.
One warning. Fixed text is text you did not say for this patient. Before signing, read it as well and check that every sentence matches the examination you have just done. So put into the template only phrases you are sure hold every time.
5. Writing style instructions
Each section can have a writing instruction, and the template can have one that applies to the whole report. Write instructions short and concrete, as if you were giving them to a junior colleague:
- “Full sentences, no bullet points.”
- “Measurements in millimetres.”
- “Conclusion in two sentences at most.”
One instruction, one thing. A long wish list is harder to check than three clear rules.
What goes in the template and what goes in the dictation
The template holds what does not change from patient to patient:
- section names and their order
- fixed phrases
- writing style instructions
The dictation holds what applies to this patient only:
- complaints and the reason for the visit
- what you found, with measurements and the side of the body
- conclusion and recommendations
If you catch yourself dictating the same sentence in every report, it belongs in the template. If the template contains a sentence you often delete, it belongs in the dictation.
Your own Word template or a template by specialty
If your institution already has a Word template, you can use it, and you download the report as a Word document. That is a good choice when the look of the document has to stay the same as before.
If you do not have a Word template, or you write different reports for different examinations, create templates by specialty: one for each kind of report you write often. We set up the template together with you, on a report from your specialty.
Before the first real report
Dictate one made-up report and read it from start to finish. Look at three things: whether every sentence is in the right section, whether the style matches the way you write, and whether the report contains anything you did not say and that should not be there. Whatever is not right, correct it in the template and repeat.
The template does not change what matters most: you read every report, correct it if needed and sign it. AiMED Dictate is a documentation tool. It does not make diagnoses and does not suggest therapy or doses.
Next step
The animated presentation at the top of the How it works page shows the same dictation before and after the template. If you would like us to set up your template together, request a demo.
