Published May 12, 2007
Nurse-One
158 Posts
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.
I understood that they had more than one dictations to complete on a busy schedule, so is that the case with nurses too?
MikeyJ, RN
1,124 Posts
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.
sirI, MSN, APRN, NP
17 Articles; 45,819 Posts
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.
core0
1,831 Posts
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
beckinben, CNM
189 Posts
I have had to dictate. The growing use of EMR is decreasing the amount, though. I personally can't wait until dictation goes away.
Becki (CNM)
traumaRUs, MSN, APRN
88 Articles; 21,268 Posts
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.
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?
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.
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.