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dictation part of the job

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by Nurse-One Nurse-One (Member)

Nurse-One specializes in future speciality interest: Nurse Midwif.

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I know doctors have to do this, but i'm wondering if a nurse at any level especially one with a masters degree or higher have to dictate their patient findings. I use to be a medical transcriptionist and one of the main challenges of the field was trying to make out a word, phrase, or sentence that the physician recorded because he/she was talking too fast, too low, heavy accent, noise in the background, you name it.:uhoh3:

I understood that they had more than one dictations to complete on a busy schedule, so is that the case with nurses too?:confused:

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MikeyJ is a RN and specializes in Peds, PICU, Home health, Dialysis.

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My partner works in the IT field for an international medical transcription company, and I have transcribed for them before and have transcribed dictated reports from MD's, PA's, and NP's.

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sirI has 30 years experience as a MSN, APRN, NP and specializes in Education, FP, LNC, Forensics, ED, OB.

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I know doctors have to do this, but i'm wondering if a nurse at any level especially one with a masters degree or higher have to dictate their patient findings.

Yes. All the time. It would be impossible for me to hand write the MR both in the clinic and in the hospital and be productive.

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Yes. All the time. It would be impossible for me to hand write the MR both in the clinic and in the hospital and be productive.

We use EMR in our clinic (although some of the physicians still dictate some of their encounters). In the hospital we dictate all our consults just like the physicians. NP's do the same. The key to dictation is to use templates if the system supports it.

David Carpenter, PA-C

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traumaRUs has 27 years experience as a MSN, APRN and specializes in Nephrology, Cardiology, ER, ICU.

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I do dictate histories and physicals and consults. The main reason for this is that I usually try to directly admit my patients from the dialysis units and I dictate into the hospital system where the pt is admitted. We have five different hospitals with five different dictation systems.

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Nurse-One specializes in future speciality interest: Nurse Midwif.

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Thanks for the replies...

So, dictating is a option to complete the Patient's medical record faster and to lighten up the work load. Who pays the medical transcriptionist to type up these recordings? Is it something a NP would have to compensate for somehow?

Is this something (dicating) you learn while on the job by your employer or is it taught somewhere within your education while in school?

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sirI has 30 years experience as a MSN, APRN, NP and specializes in Education, FP, LNC, Forensics, ED, OB.

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Clinic and/or hospital pays the transcriptionist where I work.

Wasn't taught this in any program.

I appreciate the transcriptionist's, too. I try to enunciate appropriately and will spell out troublesome words as well. Now, I do speak rather fast, but I've not had any complaints.

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traumaRUs has 27 years experience as a MSN, APRN and specializes in Nephrology, Cardiology, ER, ICU.

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I worked as a med transcriptionist after my pre-reqs for my LPN. This was back when they had the little tapes. lol

Also - I do speak fast but consciously slow myself down (and include my cell number if they have problems). I have not had any complaints.

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