• Enter your 3-digit Dictation ID number.
• Enter your 2-digit Work Type.

• Enter the 6-digit HUN (Medical Record Number)
• Begin dictation. Hang up when finished or to dictate another report, press the 8 key and follow the voice prompts to enter the work type and HUN for your next dictation.

1. Please dictate in a quiet room with little or no background noise. Keep in mind that noices such as fire alarms, overhead announcements, people talking loudly, and pagers create a great deal of background noise. It is very diffeicult for the transcriptionist to interpret your dictation.
2. Hold the handset a normal distance away from your face, as if you were speaking on a telephone, to avoid creating a muffled sounding voice. Speak loud enough to be heard clearly. Pronounce each word so it is understood.
3. Remember, you do have the ability to pause your dictation bypressing the 6 key on the keypad. We recommend using this function so that you will not be disconnected from the system due to a lengthy silence.
4. Place the appropriate format in front of you while dictating. Even the most skilled dictator will occasionally forget a heading.
5. Clearly indicate what report type you will be dictating, if you are an ARNP, PA-C or RN dictating for a physician, PLEASE indicate which physician you are dictating for at the beginning of the report.
6. Dictage the patient's medical record number and spell the patient's first and last name. Even the simplest of names have many different spellings.
7. Follow the order of the format for each report type.
8. If you should require a carbon copy to be sent to another doctor, please say their first and last name. We have several doctors at Munroe with the same last name or similar sounding last name.

1. Patient's name (First and Last)
2. Patient's HUN # (Medical Record Number)
3. Date of admission
4. Chief Complaint
5. History of Present Illness
6. Past Medical History
7. Past Surgical History
8. Allergies
9. Medications
10. Family History
11. Social History
12. Review of Body Systems
13. Physical Examination
14. Impression

15. Plan

1. Patient's Name (first and last)
2. Patient's HUN # (Medical Record Number)
3. Date of admission
4. Chief Complaint
5. History of Present Illness
6. Past Medical History
7. Past Surgical History
8. Family History
9. Social History
10. Review of Body Systems
11. Medications
12. Physical Examination
13. Laboratory and Diagnostic Data
14. Admission Diagnosis/Impression
15. Treatment Plan or Planned Course of Action

1. Patient's Name (first and last)
2. Patient's HUN # (Medical Record Number)
3. Date of Admission
4. Date of Surgery/Procedure
5. Primary Surgeon/Physician
6. Assistant(s)
7. Preoperative Diagnosis
8. Postoperative Diagnosis
9. Procedure Performed
10. Anesthesia 
11. Estimated Blood Loss
12. Specimen(s) removed
13. Drains
14. Complications
15. Indications or Findings
16. Description of Procedure

1. Patient's Name (first and last)
2. Patient's HUN # (Medical Record Number)
3. Date of Admission
4. Attending/Referring Physician
5. Date of Consultation
6. Consulting Physician
7. Reason for Consultation
8. History
9. Past Medical History
10. Past Surgical History
11. Allergies
12. Family History
13. Social History
14. Physical Examination
15. Laboratory and Diagnostic Data
16. Impression or Assessment
17. Plan/Recommendations

1. Patient's Name (first and last)
2. Patient's HUN # (Medical Record Number)
3. Date of Admission and Discharge
4. Admission Diagnosis/Reason for Hospitalization
5. Discharge Diagnosis
6. Hospital Course - including significant findings, procedures performed and treatment rendered.
7. Condition of the Patient on Discharge
8. Discharge Medications
9. Discharge Instructions/Instructions for patient and/or family, if any

1. Patient's name (first and last)
2. Patient's HUN # (Medical Record Number)
3. Date of admission
4. Date of study
5. Clinical information
6. Procedure
7. Results
8. Interpretation
9. Plan/Recommendations

1. Patient's name (first and last)
2. Patient's HUN # (Medical Record Number)
3. Date of admission
4. Age
5. Room #
6. Test #
7. Date the test was recorded
8. Technologist's initials
9. Requesting/Referring physician
10. History
11. Findings
12. Impression
13. Plan/Recommendation

Pulmonary Function Test

Physical Examination Requirements for History & Physical Reports
It is imperative that all components of the physical examination be included in your dictation, as well as your handwritten physician progress notes.

Physical Examination:

General:
Vital Signs:
Heent:
Neck:
Lungs or Pulmonary or Chest:
Heart or Cardiovascular:
Abdomen:
Back:
Genitourinary:
Extremities:
Neurological:

It is imperative that all components of the physical examination be included in your dictation, as well as your handwritten physician progress notes.

Physical Examination:

General:
Vital Signs:
Area of Specialty:

Unsafe Abbreviations

The use of certain medical abbreviations can result in medication errors, especially when handwritten, because they may be misread as something entirely different. For example, QD may be misinterpreted as QID. The following abbreviations should never be used anywhere in the medical record: