When documenting a patient encounter, it is essential to record the “nuance” of that particular patient’s history, your findings, and the care that you provided. Every patient is unique, and the “click notes” functionality in today’s EHRs is simply not capable of recording that kind of detail. You don’t want the last 10 headache patients to all sound the same, right?
Creating "generic" notes can compromize patient care provided by us and others. The only way to capture the subtleties for each patient is to add specific text in addition to clicking. This can be done via keyboard or speech recognition software. Typing (no matter how fast you are) is a terrible waste of your time, talents, and efficiency. With the increasing pressures to do more in less time, we also tend to cut corners, decreasing the quality of our documentation.
When using speech recognition software, there are a number of ways to be most efficient:
- Make corrections by voice, instead of using your keyboard. This is faster, and also helps the software to become more accurate over time.
- Use Custom Commands (macros) to insert chunks of repetitive text into your notes instead of dictating the same things repeatedly for each patient. This functionality works best for standard physical exams, review of systems, procedures, and patient education sections of the notes which can tend to be repetitive. The inserted text can then be easily modified by voice for any variations related to a specific patient.
- Schedule an “experienced user class” so you can learn (and re-learn) techniques for using the software most efficiently. These are done remotely, one-on-one, and customized to your current skills and future goals, lasting 1-1.5 hours per session. Our clients almost always experience an ”Ah-Ha Moment” in the first few minutes of these sessions. Just as you attend regular CME sessions to keep your medical skills up to date, you should consider sharpening your medical speech recognition skills at least once a year. See: Dragon Training
- Upgrade to the most recent version of the speech recognition software; this will give you noticeably increased speed and accuracy. For Dragon Medical, you can purchase an upgrade to Dragon Medical Practice Edition-4 (version 15) for about 1/3 the cost of a new license. With SayIt, your monthly subscription includes automatic updates on a quarterly basis.