DICTATION

The following reports may be dictated:

1. Discharge Summaries

2. Operative Reports

Any telephone on campus may be used to dictate. Cell phones may not be used for dictation. Call 26600 to dictate discharge summaries and operative reports. University Hospital Clinic Notes and Referring Physician Letters - Call 26611 to dictate UHC clinic notes and letters to referring physicians.

All reports must be appropriately identified with the following:

1. Patient’s Full Name (please dictate and spell the name)

2. Dates of Admission, Discharge, or Operative Date

3. Unit History Number

4. Attending Physician or Faculty Surgeon

5. Full Name and Complete Address of Referring Physician

Please dictate clearly and succinctly.

Copies of transcribed operative reports are available through your clinical department.

UTMB DICTATION SYSTEM

DIGITAL VOICE, INC. (DVI)

UTMB is pleased to present the digital dictation system for your convenience. Hands-on training is offered in the Record Processing Division, by the satellite MRT’s, and by the Transcription Division.

* The system will guide you through entry into the system with verbal prompts.

* When correct numbers are entered, access to any document in the system is immediate, and transcription turnaround time is within 24 hours.

* The system will allow you to call into the system on a touch-tone phone and listen to reports.

ENTERING THE SYSTEM TO DICTATE INPATIENT, DSU, AND OBSERVATION REPORTS

· Dial X26600 (Dial X70000 to dictate clinic notes and referral letters)

· Enter your 4 digit physician I.D. number and press #

· Enter the one digit work type number (i.e., 1#=Operative Report) and press # (correct work type very important

· Enter the 6 digit patient unit history number (i.e., 123456) minus the alpha character. The alpha character (i.e. “P” or “Q”) will be dictated along with the medical record number.

· Enter the attending physician I.D.

· Press 2 to begin dictating

· Editing Controls

2=Record On/Off

3=Short Review

77=Full Rewind

2=Stop Playback

44=Fast Forward to End

· Press 8 to start your next report

OR

Press 5 and hang up.

NOTE: Repeat steps 3-7 for each report

Note: Only with your compliance will we be able to serve you in the most efficient manner. Appropriate routing depends on your accuracy.

For assistance, please call x21840 or x73333

DICTATING HINTS

1. ENTERING IDENTIFYING NUMBERS: When dictating, each number should be pushed individually. If numbers are entered too fast, the numbers may be transposed or not registered by the system. This is extremely important in identifying reports for inquiries regarding dictation or transcription status.

2. PATIENT AND PHYSICIAN IDENTIFICATION: Dictate your name, the patient’s name (spell name), and UH# at the beginning of each dictation. If you are called away and return to complete a dictation, it is very important that you verbalize the items listed above.

WARNING: You cannot be cleared of record work you have completed, unless you include all report header information (patient’s UH#, the attending’s ID#, admission/discharge date, and date of operation, if applicable) and the work type.

3. ACCESS TO SYSTEM: Enter 3 after beginning of dictation of automatically reverse and play back to ensure access into the system. This should be done at random during dictation to be sure you have not been disconnected.

4. DATE OF OPERATION: When dictating Operative Reports, please give correct date of operation. This is necessary to clear you of delinquent operative reports.

5. OUTPATIENT OPERATIONS: When dictating outpatient procedures, always dictate correct date of operation, patient name, unit history number, and faculty surgeon’s name. Ophthalmology and Otolaryngology residents please take notice as quite a bit of treatment delivered is performed in that area.

6. ADMISSION AND DISCHARGE DATE: When dictating Discharge Summaries, always include admission and discharge dates.

7. MISSING DATA FROM REPORTS: Include all required information as outlined in your handbook. If, for example, CHIEF COMPLAINT is missing, that report is considered incomplete.

8. DATA NOT DICTATED: Should you have some missing data on your initial dictation, such as physical examination, you can dictate that portion on the system,

simply stating that your are completing a dictation on whatever the patient’s name is and continue to dictate the missing portion only.

9. UNKNOWN ID NUMBERS: For Discharge Summaries, Faculty ID# is located on the Deficiency Sheet and Data Sheet in the medical record. If you need an ID number for a faculty physician, please call x21840 or x73333.

10. TDCJ: When dictating on a TDCJ patient, indicated this and give the TDCJ patient number.

11. REFERRING PHYSICIANS: Names and addressed of referring physicians must be dictated in order for a copy of the report to e sent to the referring physician.

12. INCOMPLETE DICTATION: If for some reason you are not able to complete dictation, make a note as to where you are in the dictation and let the Transcription Area know you have an incomplete dictation. If Transcription is not notified, the dictation will be typed and sent through as an incomplete dictation. Later, when you return to complete this dictation, re-enter all of your numbers in the system and state that you are completing dictation which you had previously started. The two parts of the report will then be merged.