Dictation

Dictation

Dictation is the practice of recording the information to be placed in the note section of a patient's chart via voice recorder. This recording is sent to a transcriber who will type the recorded message and insert the electronic hard copy into the patient's chart.

Voice recognition software that automatically transcribes recorded words is quickly gaining popularity amongst medical providers who choose to dictate their note rather than type it in.

Dictation Marker

Introduction

The Dictation Marker is defined by Allscripts as the Enterprise EHR clinical database identifier for a transcription request associated with an existing note.

Dictation Markers are in essence a place holder in a structured note. When an inbound document is filed via an interface with a dictation marker, the text of the document is filed into the place holder instead of creating a separate document.

Setup in AE-EHR

Create the Document Type of Dictation Marker with Code and Mnemonic of DMRKR

1. Log in to TWAdmin.
2. On the vertical toolbar (VTB), click Dictionaries.
3. From Dictionary box, select Document Type.
4. Click Add.
5. Enter a Code = DMRKR, Name = Dictation Marker and Mnemonic = DMRKR for the document type.
6. Save your changes.

Create the TW Worktype of Dictation Marker with Code and Mnemonic of DMRKR

1. Log in to TWAdmin.
2. From the VTB, click Dictionaries.
3. From Dictionary box, select TW Worktype.
4. Click Add.
5. Enter Code = DMRKR, Name = Dictation Marker, and Mnemonic = DMRKR.
6. From the Document Type drop down box, select Dictation Marker document type to link to the TW Worktype.
7. To link the TW Worktype to a particular site, click the Sites button.
8. From the Available Sites box, select the appropriate site.
9. Click Add to assign the TW Worktype the selected site.
10. Click OK.
11. Save your changes.

Set the Dictation Marker Worktype preference in TWAdmin -> Dictate Admin to be DMRKR

1. Log in to TWAdmin.
2. From vertical toolbar, click Dictate Admin.
3. From Dictate Preferences, enter 99 for Dictation Marker Worktype.
4. Save your changes.

Deactivate TW Worktype and Document Type just created

1. Log in to TWAdmin.
2. Go to Document Type dictionary and find ‘Dictation Marker’ item.
3. Select Dictation Marker and select the Inactivate checkbox.
4. Save your changes.
5. Repeat the above steps to deactivate Dictation Marker worktype

• Deactivating the DMRKR Document Type and TW Worktype is an important step, otherwise users will be able to create dictations without dictating against a dictation marker, which will ultimately not resolve back to the original note once returned. Users would also be able to select the Dictation Marker unstrucutured document type when creating notes if is left active.

Setup and Information for Transcription Vendors

• In the previous section, the preference in DictAdmin was set
• Based upon the preference setup, instruct the vendor that if they get an XML file with <DOCUMENT_CODE> set to "DMRKR" it means that it is a dictation marker instead of a full dictation. Thus the vendor need only to send the transcribed text back with no formatting.
• The interface can convert the rtf (if sent) to ascii and fill in the dictation marker with the transcribed text.