In-Room Dictation: How One Change in Your Work Habits Can Have a Big Effect

August 01, 2002
Advance Newsmagazines for Nurse Practitioners
by Jeanne M. Boudrieau, NP

“I once spent the time between visits on dictation; now I use it for callbacks, refill requests and miscellaneous paperwork,” says Jeanne Boudrieau, author of this article. Jeanne is a staunch advocate of redesign, having been on the redesign team for Patient Visit Redesign™ training at Mark Reed Healthcare Clinic in McCleary, Washington, where she is a Family Nurse Practitioner. She also coached redesign teams in the Coleman Associates New York City Patient Visit Redesign™ Collaborative in 2003. Besides her clinical practice, Jeanne is currently active promoting healthcare access and medical education in the state of Washington. In addition, she is the owner of TeamMed, Inc. (www.teammed.org), a company which provides continuing medical education.

The providers at our busy rural family practice clinic have been brainstorming ways to work smarter, not harder. With this in mind, I decided to try something new, dictating in front of the patient. I’ve been very pleased with this career improving experience. My partner, Samantha Ritchie, MD, told me about an article she read about in-room dictation (Teichman PG. Seven reasons to dictate in the presence of your patients. (available online at http://www.aafp.org/fpm/20010900/37seve.html from Family Practice Management). This article cited seven reasons to adopt the practice: clarity, efficiency, income, malpractice risk reduction, improved care, patient satisfaction and simplicity. Clear, convincing messages in the article suggested that by simply moving the location of our dictation to the exam room, our practice would benefit. We discussed the concept and thought it would be worth a trial.

Overcoming Concerns

My initial goal was to improve my productivity during office hours. At first I was incredibly self-conscious. When do you start dictating? As you begin the history, after the exam, or at the very end? And how do you pull it all together while maintaining a therapeutic milieu? I was concerned that it would seem selfish. I didn’t want patients thinking I was more interested in getting home early than doing a good job for them.

It took a few weeks of honing my technique before I adopted the practice on a daily basis, and I have to admit there were days when I thought it wasn’t suitable for me. But now that I’ve worked through those initial challenges, it seems quite natural. Patients tell me they like it. The time I once spent between visits on dictation I now use for callbacks, refill requests and miscellaneous paperwork. I am getting home earlier, and I am more productive.

The Process

So how is in-room dictation done? I enter the room, greet the patient and say, “I’m trying a new technique to improve your care by dictating in front of you. Is this OK with you? Please stop me if I say anything that isn’t accurate.” Then I take the history and dictate it before I do the exam. At the conclusion of the exam, I amend the history as necessary related to any further discussion or findings, dictate the exam, assessment, plan, billing code, and end by saying “visit dictated in patient’s presence.” This takes just a few minutes.

Throughout dictation, I make eye contact with my patients and have found that they nod in agreement or offer corrections. With the dictaphone work completed, I review the plan again as I update the problem list, complete the encounter superbill and any necessary prescriptions. With experience, I have learned to give the dictaphone a low profile place in the visit. It’s become second nature: held beneath my chin, it doesn’t get much notice. Patients have accepted the technique as standard practice and a rhythm has developed.

Not all visits are appropriate for in-room dictation, but I find it’s acceptable for the majority. The decision to dictate in-room will depend on the occupants in the room and the nature of the visit. I include the presence and relationships of additional occupants in the note.

Occasionally, amendments are made post-visit, and these are made clear in the note. Some patients lack the ability to cope with hearing me say they look anxious, depressed, overweight, have poor dentition, odor of alcohol, or appear unkempt; while for others, stating this same information in a non-judgmental way is a good trigger for discussion and management of disease processes. Likewise, some bio-psychosocial issues or mental illnesses do not lend themselves well to in-room dictation. One example is a female patient with a breast mass who nearly passed out while listening to my partner dictate notes about the examination of her breast. You will develop a sense of when and how to employ in-room dictation.

Multiple Benefits

Patient response to in-room dictation has been positive. A patient with an industrial injury said, “I like knowing how my injury documentation reads.” A mom with a sick teenager said, “Wow, I had no idea all the stuff you think about when my child has a fever, swollen glands and a sore throat. Now I understand why you won’t phone in antibiotics.”

I have noticed that by dictating plan statements such as “patient reminded to return to clinic for Pap smear in 1 month” or “fasting lipid panel in 3 months,” continuity of care has improved. I have received strong, positive messages that patient satisfaction has improved, that my provider-patient relationships have strengthened and that patients feel more connected to their treatment plans.

I highly recommend a trial of in-room dictation. It has truly been a career-improving experience, and I am now teaching the technique to the FP residents and NP students I precept. By simply moving the location of dictation to the exam room, I have improved both the quality of my patient care and my work life. I am a happier, more productive nurse practitioner as a result of adopting this new approach to my practice.

We continue to challenge ourselves to become yet more efficient and are currently exploring ways to become a paperless office. Until we find a suitable electronic medical record, this change will do nicely.

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