More info in patient care reports will help prevent errors and delays

April 20, 2018

Training

Physicians, nurse practitioners, and others who dictate care reports should say vital patient information at the start of their dictations. This extra step prevents errors and delays in the flow of patients’ information, which keeps patients safe.

After signing in to the new provincial dictation and transcription system, clinicians who dictate reports enter a series of numbers using their telephone keypad. These numbers reflect the care report type they are dictating, the patient’s medical record number, the location they are dictating from, and more. It is customary for many clinicians to jump straight into dictating the body of their report once they have punched in these numbers.

However, there is a better way.

Say this at the start of the report

We recommend each clinician say the following at the start of their dictation:

  • the full name of the patient
  • the patient’s medical record number
  • the clinician’s location
  • the date of the care event, and
  • the first name, last name, and speciality of any intended recipient(s)

For example, after punching in numbers via the keypad, a clinician dictating a report would say:

Dr. John Doe dictating a (care event/work type) for Jane Smith, MRN 1234, seen on (date of care event). Copies to Dr. Tom Jones, (specialty and location), and Dr. Richard Smith, (specialty and location).

This tip and a few other ones are in the new provincial dictation manual.

The new edition also provides more clarity as to which report work type should be used for which care event.

NEW: Use work type 2 for all consults

Please be advised that consult work type 2 should now be used whenever that service is provided, irrespective of patient location (whether inpatient or outpatient). This new instruction can also be found in the latest edition of the provincial dictation manual.

Another tip

Using the Fluency Mobile app on your smartphone is another way to reduce the chance of transcription delays and errors. Find out how to get this app and configure it for use in Saskatchewan by calling eHealth at 1.888.316.7446.


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