Physician Dictation Guide:
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Little words can stop a transcriptionist cold . . .

Some words seem to be difficult to hear clearly when transcribing. Even a thorough knowledge of terminology, medicine and anatomy will not help if a transcriptionist cannot hear if the physician said “inter” or “intra” as these prefixes can legitimately precede many words and make sense in context. Make sure to emphasize the ending with words like this, as in “inTRA,” “inTER.” You could also say “intra, that's “RA.” (Saying each letter separately.) The transcriptionist will know to what you are referring. Whenever possible, do not use contractions. Avoiding contractions can even improve the accuracy of transcription from poor dictators. For instance, a poorly-enunciated “doesn't need” can sound like “duzzzneed” which can sound exactly like “does need.” If this error is made and not caught one can only imagine the different life-threatening situations that could occur. This nightmare can be avoided by dictating clearly “does not need.”

Since even small words can change the whole intent of a report or thought, it is very important to get into the habit of saying them clearly. Even not clearly saying, or not saying loudly enough, words like “in,” “an,” “on,” “and,” “if,” “off,” “of,” “has,” or “is,” can send a transcriptionist into a frenzy. 

Here is just a short list of words that should always be said clearly to avoid errors:

• adeno / adreno
• fasciculation / vesiculation
• has / had / have
• hema / hemo
• hyper / hypo
• in / an / on / and
• intra / infra
• intra / inter
• is / as / has
• linguo / laryngo
• of / off
• para / peri
• pyelo / pyloro
• super / supra
• uretero / urethro / utero

“spasms stop” or “spasm stop?”

One should also be careful about some pluralised words preceding other words. For example, consider the statement: “This medication did not make the spasms stop.” If not said clearly, the transcriptionist may not be able to tell if the dictator said “spasm” or “spasms.” This is not a big problem if there has been earlier references to either “a spasm” or “spasms.” But, if there is not an earlier reference, the transcriptionist has a dilemma, as it could well be medically-significant to a physician whether the patient had a single spasm or multiple spasms. In this situation, the proper way to dictate is to prolong the “zzz” sound if the word is “spasms” or the “mmm” sound if the word is “spasm.” For example, if the word is “spasms” you would dictate the sentence as “The medication did not make the spasmzzz stop. Full stop.” One could also say: “The medication did not make the spasms stop.” Then you say “That's 'spasms stop,' plural.” Then continue “Full stop.”

Continued . . .

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