Telephone Dictate Instructions

Dial 671-2103 (Dial extension 2103 from inside the hospital).

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

10 Discharge Summary

33 Death Summary

20 History & Physical

16 Sleep Study

30 Operative Note

37 Pulmonary Function Test

40 Consultations

90 EEG

50 Pre-Operative History & Physical

28 Short Time Record

  • 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.

Control Keys

1 Listen

6 Pause

2 Record

7 Go to Start of Report 

3 Short Rewind

8 Complete/Next Report 

4 Go To End of Report

 


Suggestions for 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.

Pre-Operative History & Physical

Must be completed and documented for each patient no more than 30 days prior to surgery/procedure requiring anesthesia. When HP is completed and documented within 30 days of admission/registration, an updated HP must be completed prior to surgery/procedure for requiring anesthesia.

  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


History and Physical

Must be completed and documented for each patient no more than 30 days prior and no less than 24 hours of admission/registration.

  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

Operative Report

Complete operative report must be dictated by the surgeon immediately or no longer than 24 hours post surgery/procedure.

  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

Consultation

Completed and documented within 24 hours of consultation, preferably immediately following.

  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

Discharge Summary

Completed and documented within 30 days post discharge.

  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

Polysomnogram

  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

Neurophysiology Interpretation (EEG)

  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

  1. Patient's name (first and last)
  2. Patient's HUN # (Medical Record Number)
  3. Date of admission
  4. Date of test
  5. Requesting/Referring physician
  6. Patient profile/Clinical information
  7. Description
  8. Interpretation
  9. Plan/Recommendation

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:

Physical Examination Requirements for Consultation 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:
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:

AbbreviationPotential ProblemPreferred Term
U (for unit) Mistaken as zero, four or cc. Write "unit"
IU (for international) Mistaken as IV (intravenous) or 10 (ten). Write "International unit"
Q.D., Q.O.D (Latin abbreviation for once daily and every other day) Mistaken for each other. The period after the Q can be mistaken for an "I" and the "O" can be mistaken for an "I" Write "daily" and "every other day."
Trailing Zero (X.0mg), lack of leading zero (.Xmg) Decimal point is missed. Never write a zero by itself after a decimal point (Xmg), and always use a zero before a decimal point (0.Xmg)
MS, MS04, and MgS04 Confused for one another. Can mean morphine sulfate or magnesium sulfate. Write "morphine sulfate" or "magnesium sulfate"
ug (for microgram) Mistaken for mg (milligrams) resulting in a one thousand-fold overdose. Write "mcg"