Literary Escapades of Internship…

Rachel Boykan, MDAssistant Professor of Pediatrics

Pediatric HospitalistStony Brook University Department of

PediatricsJuly 29, 2009

1. At the beginning of the dictation, take the deepest breath you possibly can and then try to dictate the entire report before you have to inhale again.

2. When dictating a particularly difficult word or phrase, please turn your head and speak directly into your armpit.

3. If you have to sneeze or cough suddenly, please remove your head from your armpit and sneeze or cough directly into the microphone.

4. If you must eat while you dictate, please stay away from foods such as marshmallows, bananas, and pudding; apples, pretzels, and celery are much better choices.

Copyright 2005-2006, Copied with Permission from the web site,"Patients and Medical Transcription" at http://www.mt-stuff.com

5. Please do not stop dictating when you yawn; it throws off our rhythm.

6. Do not stop dictating in the event of a minor background noise such as an office party, the janitor’s vacuum cleaner, a screaming infant, etc.; again, it throws off our rhythm.

7. Talk as fast as you possibly can. Fair is fair, after all, and we type as fast as we can!

8. Dates of admission and discharge are not important for old H&Ps or discharge summaries.

9. Abbreviate whenever possible. Everyone loves a mystery and we are trying to learn new skills, such as mind-reading.

10. Finally, be sure to wait until the end to tell us what kind of report you are dictating, or to "scratch" this dictation since it was already dictated.

Copyright 2005-2006, Copied with Permission from the web site,"Patients and Medical Transcription" at http://www.mt-stuff.com

“This is an 8 year-old child accompanied by her mother, who appears playful and interactive”

“Her fourth toe cramps and she has to take off her shoe and at times rub her foot until it goes away”

“This is an evaluation of an 11 year-old girl who suffered a fall today while ice-skating on her left wrist”

“The patient occasionally gets a rash on her neck which she has had for some time”

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A dictated summary is a written document and is part of the medical record

It may be used for medico-legal purposes

What you say in to the microphone; what the transcriptionist hears, is what is typed by the transcriptionist

Organize your data before starting transcription Dictate in a secure, quiet area Speak clearly, loudly and slowly

◦ Remember that the transcriptionist cannot read your facial expressions, ask you to repeat yourself or clarify a statement

Always state and spell your name and the name of the patient you are documenting care for

State the work type clearly Be aware of possibly misunderstood words and

spell them, give hints◦ AB duction vs AD duction, hyPER tension vs

hyPO tension Never abbreviate medications; spell uncommon

drugs Clearly state lab values, taking care that they

don’t run in to each other

Use English Speak as if you were writing

◦ Not texting◦ Not sending e mails◦ Not sending pages

Use subjects, nouns, verbs, etc. Avoid colloquialisms/verbiage of sign-out

◦ “neuro-wise”◦ “Mommy states that…”◦ “as mentioned before,” “as I said,” “to recap…”◦ “positive red reflex”

Speak clearly! Be organized

◦ Use an outline if you need to Be succinct, summarize - don’t record all the

details Use dates, not days of the week Avoid too much commentary or discussion that

does not apply to final story Follow standard format and include a physical

exam!

“The patient had pain when she saw me for several months in November”

“Bowel movements have remained stable with good appetite”

“Skin is, oh, well, uh, just take the skin off”

“Her mother looked at her ears today and brings them in today to be checked”

“External genitalia revealed normal testes and normal penis bilaterally”

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HPI“During her initial stay on the pediatric floor, she continued to develop

labored breathing, and there was a concern about respiratory failure, so she was transferred to the pediatric ICU for further care. In the ICU, the patient had a relatively uneventful stay. She continued to require oxygen and had transient desaturations on facemask down to 70 – 80%. These episodes lasted several seconds and would resolve immediately with stimulation of the patient, either by tactile stimulation or by suctioning. The patient had a positive RSV swab and negative influenza. She continued to have a fever, and subsequent chest x-ray on 5/20 showed a focal airspace consolidation on the left lower lobe. However, in light of her ______ improvement, this was felt to be secondary to RSV rather than a bacterial process. She was not continued on her antibiotics upon admission. Currently, the patient is on 2 liters nasal cannula and displaying no increased work of breathing. Dr. x, the patient’s primary attending, on 5/21, has commented that from a respiratory standpoint, she looks better than her baseline.”

ADMISSION DIAGNOSIS: Asthma exacerbation and bronchopneumonia HISTORY OF PRESENT ILLNESS: A 4- year-old female with a history of asthma was admitted

for asthma exacerbation. The patient had an increase of wheezing over the past 2 days. The day before the admission, the patient’s family noted the symptoms worsened and brought to ER. In the ER, the patient received 3 nebs and steroid and minimal improvement and had developed hives to the Atrovent that resolved with Benadryl.

HOSPITAL COURSE: The patient was admitted to the floor because the patient needed continuous nebs and still had mild retractions and was transferred to PICU for 02 saturation being less than 90 and on oxygen therapy. The patient also had a chest x-ray, which had shown possible bronchopneumonia. The patient also was having generalized abdominal pain focused. The patient, in PICU, started on IV antibiotics, ceftriaxone. The patient stayed in PICU for 1 day. On 03/25, the patient was transferred back to the floor. Pulmonary was consulted, recommended to add azithromycin along with Singulair and Flovent. The patient continued to receive total of 4 days of ceftriaxone and azithromycin. The patient was doing well, satting well on room air 92-94%. The patient was tolerating p.o. The patient was stable to discharge home. The patient was discharged to home.

FINAL DIAGNOSES:◦ 1. Asthma exacerbation◦ 2. Bronchopneumonia

DISCHARGE MEDICATIONS: Flovent 110 mcg bid, albuterol, Singulair 4 grams po at bedtime, ampicillin 800 mg po bid for additional 5 dys, Augmentin 300 mg po daily for additional 5 days.

DISCHARGE INSTRUCTIONS: The patient had a follow-up pulmonary clinic appointment within 1-2 weeks and PMD appointment on Monday. The patient was discharged home.

CC: Fever, rule out sepsis HPI: The patient is a 3-week-old male ex-NICU stay for 15 days for

intrauterine growth retardation, respiratory distress on CPAP and nasal cannula, with feeding issues on NG feeding, born at 39 weeks, transferred from St. x hospital. The patient has an unknown genetic abnormality, follows with genetics; has grade III hypospadias, follow up with pediatric surgery; has a right undescended testicle; cholestasis, jaundice, on Actigall, follows with pediatric GI; a left choroid plexus cyst, sees neurology, who presented with a 3-day history of abdominal pain, hard stools and no bowel movement for 24 hours. Mom went to the PMD, who was instructed to give prune juice on 06/04 and the patient had a stool within 24 hours. The patient has been having wet diapers of 3 per day but has decreased from a baseline of 6 wet diapers per day. The patient was having positive congestion and rhinorrhea for a day. The patient had a low-grade temperature of 100.9 tympanic, contacted PMD and was sent in to the ER for evaluation. There was a positive sick contact at home. Mother was sick and the patient was transferred to Y Hospital.

CC: Fever, cough, abdominal distention HPI: The patient is a 20-month-old male, full-term, normal

spontaneous vaginal delivery with no significant past medical history, sent from X Hospital for possible ileus. The patient started to have fevers on Monday at 102 degrees, cough, sent home with hydration. From Tuesday to Thursday, the patient was doing fine but did get some Tylenol for fever yesterday. Friday, the day of admission, the patient went to clinic for vaccination and found to have a distended abdomen. The patient transferred to x Hospital for further evaluation. The patient did not have any bowel movement today but had been having bowel movements the past couple of days. The patient’s consolable when coming to the floor. No sick contacts were reported.

CC: Trauma HPI: This is a 7-year-old male,….

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Dictations are an important and legal written part of the chart

They convey the most important information about an admission

They must be written clearly With practice and attention to the basic rules

they can be done easily and quickly Please do them within 30 days of discharging the

patient!