Dictation shortens the writing of a report. It does not shorten the reading, and it should not. A report that came from dictation is still your report: you read it, you correct it and you sign it.
This is a checklist for the review before signing. It is short on purpose, so that you can go through it for every report and not only for the ones that look suspicious.
Why these five things
An error in dictated text does not have to look like an error. A sentence can be grammatically correct and sound convincing while one word in it is not the word you said. That is why reading “by feel” does not pay off. What pays off is a targeted look at the places where one word or one digit changes the meaning of the report.
There are five such places: numbers and units, side of the body, negations, drugs and doses, and patient identity.
1. Numbers and units
Read every number in the report and compare it with what you measured or saw.
- Is the digit the same, and is the decimal point in the right place?
- Does the number carry the right unit: millimetres or centimetres, milligrams or micrograms?
- Are the dimensions written in the order you said them?
- If you gave a range, are both limits in the report?
Numbers that sound alike are worth a second look. Fifteen and fifty are easily confused in speech.
2. Side of the body
Left and right are the shortest words in a report and among the most important. For every report that has a side, check:
- whether the side in the description matches the side in the conclusion
- whether the side in the report matches the referral and what you examined
- whether “bilateral” really is bilateral
If you describe both sides in one sentence, read it slowly. That is where sides are most easily swapped.
3. Negations
“No signs of” and “signs of” differ by one word. While reading, look especially for:
- “no”, “without”, “not”, “not seen”
- sentences in which you list several things and the negation applies to only some of them
- double negations, which are better written as a positive statement
A good rule: read every sentence with a negation as if a colleague who has not seen the patient were reading it. If it can be understood in two ways, write it more simply.
4. Drugs and doses
Drug names resemble each other, and doses are numbers. So this point combines the first two risks.
- Is the drug name the one you said, letter by letter?
- Is the dose correct, and does it carry the right unit?
- Are frequency and duration next to the right drug?
- If the report lists several drugs, does each dose belong to its drug?
AiMED Dictate writes down what you dictated. It does not suggest therapy or doses and does not check them for you. The decision about the drug and the dose is yours, and so is the check.
5. Patient identity
Before signing, check that the report belongs to the patient you are issuing it to. It sounds obvious, but on a day with many examinations this is exactly what is easiest to skip.
- Are the name and the other patient details in the document correct?
- Do age and sex match what the text of the report says?
- If you enter the report into your institution’s system, is the right patient’s record open?
If you download the report as a Word document, look at the file name too before you send or print it.
Text from the template is your text as well
If your template contains fixed phrases, they are in the report even though you did not say them for this patient. Read them as carefully as the dictated part. A sentence that is correct in most reports does not have to be correct in this one.
Look at the arrangement too: whether every sentence is in the section where it should be, and whether the conclusion says what follows from the description.
How to correct
You correct the report by voice before signing: you say which word to change, which sentence to delete or what to add. Only when the text matches what you found do you copy the report, download it as a Word document or finish it in your institution’s system.
If you make the same correction in report after report, the cause is usually in the template, not in the dictation. Then it is worth correcting the template.
The checklist in brief
- Numbers and units: every digit, every decimal point, every unit.
- Side: the same in the description, in the conclusion and on the referral.
- Negations: every “no”, “without” and “not”.
- Drugs and doses: name, dose, unit, frequency.
- Patient: the right report for the right patient.
AiMED Dictate is a documentation tool. It does not make diagnoses and does not suggest therapy or doses. The report is always reviewed and signed by the doctor.
Next step
The How it works page opens with an animated presentation of the path from dictation to a signed report. If you would like to see what this looks like on a report from your specialty, request a demo.
