Friday, April 16, 2010

Short Notes on Innovative Dictation Savings

High health costs represent big ticket things - like heart surgery, hip and knee replacements, and MRIs - but also thousands of little things piled on top of each other.

One of these little things is physician dictation – an essential ingredient for documenting and charging for what the doctor did.

• Physicians often dictate what occurred during an office visit for future reference, for referral letters, or to justify a code.

• Hospitalists often dictate notes after seeing a hospital patient or performing a procedure during a patient’s hospital stay, again to tell a story or to justify a code.

• Surgeons are obligated to dictate a post-operative note for “the record” to document what was done, what was found, and for reading by doctors or lawyers or coding consultants.

Dictation is expensive. It takes a doctor’s time, it takes a receptionist’s time, and it takes money to pay the firm, often outside the doctor’s office or hospital, to process the dictation, before making it a permanent part of the patient’s record.

Yet there are obvious ways to obviate or end the need for human dictation.

• One of these is to provide “canned notes,” generic summaries in the form of check lists, that the doctor can simply check off and produce statements or paragraphs that cover something routine that is done over and over and needs not to be repeated. Canned notes save time and money and can be used to cover post-op notes, progress notes, hospital procedure notes, pre-op notes, and post-op notes.

• Another is notes entered electronically by patients, nurses, an doctors before and during a visit. These notes include patient demographics, age and sex, chief complaint, present history, past, family, and social history, vital signs, and physical findings. Using a clinical algorithm in software called The Instant Medical History can turn a computer-directed patient interview into a clinical narrative, and nurses and doctors can use checklists to fill in the rest. The patient can leave the office with a complete electronic record in hand of his or her visit.

• Finally, there is new and improved voice recognition software – Dragon Naturally Speaking and others – that allow doctors to dictate on the spot without referring dictation to transcribers or others. An additional benefit is that physicians can dictate thoughts and observations directly into the electronic medical record.

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