Tips for Effective Dictation of Medical or Patient Notes

Do you dictate or type when writing patient notes or when writing letters for status determination in Utilization Management?

I have seen a lot of doctors type while making their patient notes. I think dictating makes it way easier and quicker to finish their daily work.

When dictating medical patient notes, it is important to accurately convey the signs and symbols commonly used in healthcare documentation. These signs and symbols provide important information about a patient’s condition, test results, and treatment plans. To help you effectively dictate these signs and symbols, we have compiled a list of commonly used ones along with their corresponding dictation instructions.

1. Speak Clearly and Slowly

Enunciate your words clearly and speak at a moderate pace. Avoid rushing or mumbling.

2. Use Standardized Language

Use standardized medical terminology and abbreviations to ensure clarity and consistency in your dictation. This will also make it easier for other healthcare professionals to understand your notes.

3. Be Concise

While it’s important to provide all the necessary information, avoid unnecessary details or lengthy descriptions. Be concise and focus on the key points to make your dictation more efficient.

4. Proofread and Edit

After dictating, take the time to proofread and edit your notes. Correct any errors or omissions to ensure accuracy and clarity.

5. Practice Regularly

Like any skill, dictation improves with practice. Set aside time to practice dictating medical notes regularly to enhance your proficiency.

6. Seek Feedback

Ask for feedback from colleagues or transcriptionists to identify areas for improvement in your dictation. Their insights can help you refine your skills and enhance the accuracy of your notes.

Here are some symbols and how to dictate them that I collected from various sources and useful for doctors:

Symbol	Dictation
Add a new line.	Say “New Line”
Add a new paragraph.	Say “New Paragraph”
Start capitalizing the first letter of each word.	Say “Caps On”
Stop capitalizing the first letter of each word.	Say “Caps Off”
Capitalize the first letter of a specific word.	Say “Cap <word>”
Start capitalizing all letters.	Say “All Caps On”
Stop capitalizing all letters.	Say “All Caps Off”
Period (.)	Say “period” or “dot”
Comma (,)	Say “comma”
Question Mark (?)	Say “question mark”
Exclamation Mark (!)	Say “exclamation mark” or “exclamation point”
Colon (:)	Say “colon”
Semicolon (;)	Say “semicolon”
Quotation Marks (” ” or ‘ ‘)	Say “open quotation” and “close quotation”
Plus (+)	Say “plus”
Minus (-)	Say “minus”
Multiplication (×)	Say “times” or “multiplied by”
Division (÷)	Say “divided by”
Equal (=)	Say “equals”
Greater Than (>)	Say “greater than”
Less Than (<)	Say “less than”
Greater Than or Equal To (≥)	Say “greater than or equal to”
Less Than or Equal To (≤)	Say “less than or equal to”
Not Equal To (≠)	Say “not equal to”
/	Say “slash”
→	Say “arrow”, if that does not work say “hyphen greater than sign” [helpful for trending labs]
↑	Say “up arrow”
↓	Say “down arrow”
∆	Say “delta”
∞	Say “infinity”
µ	Say “mu”
≈	Say “approximately equal to”
°	Say “degrees”
Percent (%)	Say “percent”
Patient’s	Say “Patient apostrophe s”
“Open quotes	Say “Open quotes”
Close quotes”	Say “Close quotes”
–	Say “Dash”
underscore _	Say “Underscore”
( Left parentheses	Say “Left parentheses”
Right parentheses)	Say “Right parentheses”
[ Left bracket	Say “Left bracket”
Right bracket ]	Say “Right bracket”
{Left brace	Say “Left brace”
Right brace}	Say “Right brace”
to indent the paragraph.	Say “Indent”
to reduce indentation.	Say “Decrease Indent”
to create a new paragraph.	Say “New Paragraph” or “New Line”
Ampersand (&)	Say “ampersand”
Check Mark ✓	Say “check mark”
Cross Mark ✗	Say “cross mark”
degree Fahrenheit °F	Say “degrees Fahrenheit”
120/80 mm Hg	Say “120 slash 80 mm Hg”
Heart ❤️	Say “heart symbol”
Smiley Face 🙂	Say “smiley face”

You can highlight a text and say “bold that” or “underline that” or “copy that” or “paste that” or “undo that” depending on what you would like to do.
Not every symbol mentioned above is useful while dictating progress notes but they may be useful somewhere else.

Capitalize all letters in the last words you said.	Say “All Caps that”
Capitalize all letters in the text you selected.	Say “All caps selection”
Start lower-casing all letters.	Say “No caps on”
Stop lower-casing all letters.	Say “No caps off”
Lower-case a specific word.	Say “No caps <word>”
Lower-case all letters in the last words you said.	Say “No caps that”
Lower-case all letters in the text you selected.	Say “No caps selection”
Insert a space before or after a word or character.	Say “Space”
Start dictating text with no space in between words.	Say “No space on”
Stop dictating text with no space in between words.	Say “No space off”
Dictate a word with no space before it.	No space <word>”
Insert a tab before or after a word.	Say “Tab” or “tab key”
Force dictated numbers to appear in numeral form (“4”) rather than in text form (“four”).	Say “Numeral”
Dictated numbers appear in roman numeral form.	Say “Roman numeral”
Insert quotes before and after the last words you said.	Say “Quote that”
Insert quotes before and after the text you selected.	Say “Quote selection”
Insert brackets before and after the last words you said.	Say “Bracket that”
Insert brackets before and after the text you selected.	Say “Bracket selection”
Insert a hyphen between the last words you said.	Say “Hyphenate that”
Insert a hyphen between the text you selected.	Say “Hyphenate selection”
Compound the last words you said.	Say “Compound that”
Compound the text you selected.	Say “Compound selection”

Conclusion

By following these tips, you can improve your ability to dictate medical notes effectively. Clear and accurate dictation is crucial for proper patient care and efficient documentation. Practice regularly, seek feedback, and use technology to enhance your dictation skills.