When you record the conversation with a patient, you do not dictate the report afterwards. You turn on recording at the start of the exam and work as usual, and after the exam the text is in the template, waiting for your review. For this to work well, it is worth preparing four things: the patient, the speakers, the content of the report and the sound.
1. The patient should know that the conversation is being recorded
This is the first step, and it is not skipped. Tell the patient before you turn on recording, in simple words:
- that the conversation is being recorded
- why it is being recorded: so that you get the text of the report from the conversation
- that you still review and sign the report
One calm sentence at the start of the exam is enough. The patient should not have to discover the microphone on the desk and wonder what it is for.
How patients in your institution are informed, and where that is noted, is governed by your institution’s rules. Agree on it with the person responsible for data protection in your institution before you start recording. If a patient does not want the conversation recorded, do the exam without recording and dictate the report yourself afterwards.
2. How speakers are separated
When you record a conversation, AiMED Dictate tells your voice from the patient’s, so it is clear who said what. In the transcript of the conversation, the speakers are marked as doctor and patient.
You can help the separation by the way you lead the conversation:
- Do not speak at the same time. Wait for the patient to finish the sentence.
- If someone is accompanying the patient, say who is who when they first join the conversation.
- Repeat important details in your own words: “So, the pain has lasted three weeks and is worse at night.” That way they are said clearly, and in your voice, in the transcript.
Repeating has a second benefit. The patient hears how you understood them and can correct you right away, not later.
3. What ends up in the report
A conversation is not a report. A conversation contains greetings, repetitions, questions about parking and stories that have nothing to do with the exam. The conversation becomes text in the template you chose, arranged in its sections.
Before the report is made from the conversation, you can review the transcript and correct errors in it. It is worth using that moment for drug names, numbers and anything the patient said quietly or unclearly.
What you did not say in the conversation cannot be in the report. This most often applies to the status: what you see, feel or measure stays in your head unless you say it aloud. So during the exam, say your findings as you work:
- “Abdomen soft, not tender on palpation.”
- “Blood pressure one thirty over eighty.”
- “To finish: I recommend a follow-up in one month.”
At first it can feel unusual to say aloud what you would otherwise only write down. The patient, meanwhile, hears what you found.
At the end of the exam it is useful to sum up the conclusion and what you agreed with the patient in two or three sentences. That way the conclusion is said clearly and in one place in the conversation.
4. The room and the microphone
A web browser and a microphone are enough: a laptop, a computer or a phone. The sound quality still depends on a few simple things.
The room:
- Close the door and the window facing the street.
- Turn down what you can: the radio, notification sounds on the phone, a loud fan.
- If you can hear a conversation in the corridor, wait with the recording until it has passed.
The microphone:
- Place it between you and the patient, closer to whoever speaks more quietly.
- Do not put it next to the keyboard, the printer or a device that hums.
- Do not cover it with papers and do not move it during the exam.
- If the computer has several microphones, choose the one you want to use before recording and check that the sound level indicator reacts when you speak.
If you move away from the desk during the exam, for example to the examination couch, speak a little louder or repeat what matters when you come back.
You can pause and resume the recording. That is useful when someone interrupts you, when the phone rings, or when you talk with the patient about something that does not belong in the report.
Before the first patient
Try it with a colleague. Act out a short exam, record it and read what you got. You will see right away whether the microphone is well placed, whether you speak loudly enough, and whether the report lacks something you only thought and did not say.
What stays the same
You review a report from a conversation as carefully as any other: numbers, side of the body, negations, drugs and doses. AiMED Dictate writes down what is said in the conversation and arranges it in the template. It does not make diagnoses and does not suggest therapy or doses. You review and sign every report.
Next step
The animated presentation at the top of the How it works page shows how what is said becomes a report in a template. If you would like to try it on an exam from your specialty, request a demo.
