1. Dial 234-8255 (TALK)
2. Enter User D Number: (5 digit d-num)#
18801
3. Enter Facility ID Number:
MCE - 1#
MCW - 2#
MCSA - 3#
MCNA - 18#
Diley Ridge - 20#
MCGC - 23#
4. Enter Work Type Number:
H&P - 1#
Consult - 2#
Operative Report - 5#
Discharge Summary 9#
Endoscopy Report - 7#
ED Note - 8#
Radiology - 10#
EEG Report - 12#
ENG Report - 13#
Attending Staff Note - 15#
Clinic Note - 17#
PFT - 18#
Direct Admit H&P - 27#
Cardiac Procedure - 41#
House Physical Eval - 87#
Cardiac H&P - 88#
5. Press 2 and start speakijnng. (press 1 to pause, 2 to continue)
Beginning of dictation:
1. Patient Name (spell w/ middle initial)
2. Patient 13 digit FIN number
3. Your name as dictating provider
4. Names of physicians who need report copies (spell full name and middle initial)
7. Dictate
Chief Complaint/Reason for Consult
HPI
ROS
PMH
PSH
MEDS/ALL
SOC
FAMA
PEl
LABS
IMAGING
X-rays of --- were obtained and reviewed.
Ct of ---
PROCEDURES
A/P
At the end of the dictation
H&P or Consult: "This patient was discussed with attending physician, Dr. X, who is in agreement with the above assessment and plan as laid out in this note."
Trauma Evaluation:
"DISPOSITION: The patient’s disposition is to be determined after review of the aforementioned diagnostic studies.
The evaluation of this patient was completed in accordance with ATLS guidelines on (date) at (time). Dr. (first and last name) was present during the assessment & planning of this patient’s care & agrees with the immediate execution of this plan."
8. Record Job ID at end of report
Controlls during dictation
1 - Pause
2 - Continue (from end or over any location in dictation to redictate)
3 - Brief rewind/playback
77 - Total rewind/playback
44 - Fast Forward
5 - Disconnect
If you got cut off: Log back into system and re-input patient information. At beginning of dictation state that this is the second half of a cut off dictation
To listen to a dictation:
1. Dial 234-8255 (TALK)
2. Enter User ID prompt, enter ID number and # key
3. On Facility prompt enter *13
4. Press 3 to listen
5. Enter 13-digit FIN then #. Most recent dictation will play, press 8 to move to next report
6. Radiology reports - stored by date of birth, when prompted for facility press the # key, then date of birth 012688. Most recent will play first, press 8 to move to next report
HISTORY AND PHYSICAL
HISTORY OF PRESENT ILLNESS:
REVIEW OF SYSTEMS: A 10-point review of systems conducted and found negative as per HPI.
PAST MEDICAL HISTORY:
PAST SURGICAL HISTORY:
HOME MEDICATIONS:
ALLERGIES:
SOCIAL HISTORY:
FAMILY HISTORY:
PHYSICAL EXAMINATION:
VITAL SIGNS: Temp HR BP RR Saturation
GENERAL: NAD (no apparent distress), resting comfortably in bed, AOx3,Nut
HEENT: Normocephalic, atraumatic
NECK: Supple. No JVD
HEART: Regular rate
LUNGS: Nonlabored breathing.
ABDOMEN: Soft, non-tender, non-distended, no rebound or guarding. Incisions are CDI
LABORATORIES:
IMAGING:
ASSESSMENT AND PLAN:
This is a X y.o. M/F presenting with symptoms of X most likely due to X. Less likely etiologies that were also considered include X.
Problem - plan
Problem - plan
etc.
This patient was discussed with attending physician, Dr. X, who is in agreement with the above assessment and plan as laid out in this note.
OPERATIVE NOTE OUTLINE
DICTATED BY:
DATE OF OPERATION:
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
PROCEDURES:
SURGEON:
ANESTHESIA:
BLOOD LOSS:
FLUIDS:y
COMPLICATIONS:
DRAINS:
DISPOSITION:
INDICATIONS:
DESCRIPTION OF PROCEDURE:
DISCHARGE SUMMARY:
Date of Admission:
Date of Discharge:
Attending Physician:
Primary Care Physician:
Primary Diagnosis:
Secondary Diagnosis:
Consults:
Surgeries/Procedures:
Brief History and Physical:
Hospital Course: Either chronologically or by diagnosis
Discharge Condition:
Discharge Instructions:
**For further details please consult this patient's chart. This is a brief detail of the patient's hospital course.