Dictation Best Practices Tool Kit
The Association for Healthcare Documentation Integrity (AHDI) is actively engaged in offering our professional expertise to address the impact of problem dictation as it relates to documentation errors and critical flaws affecting patient safety, the potential for sentinel events, the effects on turnaround time, and the resulting increased cost.
The reasons for improved dictation throughout all healthcare facilities is compelling. Incomplete or inaccurate documentation as a result of poor dictation habits leads to patient-care errors and the potential for sentinel events. In addition, poor dictation increases turn-around time and threatens timely delivery of care as well as delays reimbursement. Not only is patient care affected, but unaddressed problematic dictation can consume significantly more time and labor, thereby increasing overall documentation costs. As the healthcare system rapidly moves toward adoption of EMRs and ultimately the EHR, widespread attention has now turned toward speech recognition, yet vendors consistently cite a low percentage of qualified users as a chief concern in assisting clients in adoption and implementation of this technology.
The Dictation Best Practices Tool Kit is designed to assist facilities with the adoption and implementation of policies and training practices that will promote high quality dictation and ensure the best documentation outcomes. This kit includes Dictation Best Practices: A Guide for Physicians, a self-running audiovisual presentation, as well as a PowerPoint presentation with handouts for a live seminar. In addition, the kit includes the rationale for promoting better dictation practices and Dictation 101, recommendations for instructing dictators in good dictation habits. Visual aids include "Q" Cards, a Tip Sheet, and a Documentation Workflow poster.
We would like to express our sincere appreciation to M*Modal for generously sponsoring the production and distribution of the Dictation Best Practices Tool Kit. AHDI is proud to work with M*Modal toward improved practices in dictation.
A Note from AHDI – A welcome letter from the association.
How to Use This Tool Kit – The document you are now reading that outlines all elements of the tool kit.
Rationale Document – The overview document that provides statistical data and legal support for why improved dictation practices will lead to quality documentation outcomes.
8-Minute Orientation – This document is designed to assist the trainer/educator in conducting a quick training session with new dictators on the fundamentals of best practices as well as facility-specific and/or equipment-specific processes.
Dictation 101 – A handy resource document to prepare the trainer/educator for covering the 4 critical considerations for better dictation habits as well as some practical exercises and scenarios for reinforcing this information.
Orientation and Training PowerPoint – A quick presentation for use during orientation/training sessions that provide attendees with rationale, tips, and strategies for adopting good dictation habits. (Note: This can be customized to include facility-specific or equipment-specific training slides.) Also included in this kit are these supplemental handouts:
Orientation and Training Slides Handout – A handout of all slides used in the presentation.
Orientation and Training Notes Handout – A set of slide pages that include space for taking notes.
Dictation Tip Sheet – A take-away handout for dictating providers and new trainees with quick tips to remember when dictating. This tip sheet can also be posted in designated dictation areas and physician offices to communicate your goals for best practices in dictation. Note: AHDI strongly recommends facilities modify/customize this tip sheet to reflect facility-specific guidelines, equipment specifications, policies, and procedures to ensure that application of these tips best meets the needs of your organization.
Sample Q Cards for Dictators – We recommend providing quality cards (Q cards) to dictators for quick wallet access when dictating from facility dictate stations or remotely from another access point. This document provides a sample of what such a resource could look like for your organization, with equipment procedures on one side of the foldable 4-panel card and document types and formats on the other side.
Model Policies & Procedures – The core document of this tool kit, these sample policies and procedures can help guide facilities in establishing sound policies for improved and sustained best practices in dictation. This document includes sample communications for reporting and addressing dictation issues.
Strategies for MTSOs – A resource document for transcription services owners who, by the nature of their contractual relationship, may or may not have direct access to providers for the purpose of addressing dictation concerns. This document provides tips for how to address this contractually as well as strategies for working with facility contacts and clients to improve dictation practices.
If you have any questions about how to integrate any of these tool kit pieces into your organization or have suggestions and/or feedback for future editions of this kit, please contact AHDI (firstname.lastname@example.org).