Can I dictate my patient encounter?

Dictating Patient Encounters: Best Practices for Patient-Centered Communication

Yes, you can dictate your patient encounter, but you should follow specific best practices to maintain patient-centered care and effective communication.

Key Considerations for Dictation During Patient Encounters

Ask Permission First

• Always ask the patient's permission before dictating notes during the encounter 1
• Explain the purpose of dictation (e.g., to ensure accurate documentation of their medical information) 1
• Inform patients about what you're documenting as you dictate 1

Positioning and Body Language

• Use a postural style that allows you to face the patient most of the time 1
• Position yourself so your head and torso are oriented toward the patient while interacting with technology 1
• Maintain eye contact and positive nonverbal behavior during dictation 1

Communication Strategies During Dictation

• Talk while working on documentation to maintain engagement with the patient 1
• Verbalize your actions (e.g., "I'm documenting your blood pressure reading now") 1
• Use affirmative speech (e.g., "I see," "mm-hmm") and nodding while dictating to show attentiveness 1
• Avoid interrupting patients when they are expressing concerns - patients typically express about three concerns per office visit and take only about 32 seconds to complete their list 1, 2

Screen Sharing and Patient Involvement

• Invite the patient to view the screen before they ask 1
• Involve patients in building their medical chart 1
• Consider sharing the screen to promote patient participation 1

Benefits of Patient-Present Dictation

• Improves transparency in the medical documentation process 3
• Can help patients understand their condition and treatment recommendations 3
• 73% of patients in one study liked being present during dictation 3
• Older patients (56+ years) reported improved understanding of provider recommendations when present during dictation 3

Potential Pitfalls and How to Avoid Them

Avoiding Divided Attention

• Separate computer use from communication when building rapport or discussing treatment options 1
• Use verbal cues or gestures to indicate switches in attention between the patient and documentation 1
• Use gaps in interaction (e.g., when patient is dressing after examination) for computer work 1

Preventing Communication Barriers

• Avoid medical jargon that patients may not understand 4
• Remember that patients who know their physician's name and have a clear understanding of their management plan report higher satisfaction 5
• Be aware that dictation should not replace proper agenda-setting, which directly impacts patient outcomes 2

Documentation Requirements

• Document telephone encounters consistently if you're dictating phone encounters 1
• Include date, time, patient information, reason for encounter, relevant history, assessment, plan, and disposition 1
• Place documentation for all encounters for which a patient is charged in the medical record 1

Special Considerations

• Male patients tend to feel more positive about dictation in their presence than female patients 3
• Older patients (56+ years) tend to be more positive about dictation in their presence 3
• Consider reviewing the patient's medical record before calling them in to maximize face-to-face time 1

By following these guidelines, you can effectively dictate patient encounters while maintaining patient-centered care and effective communication.