Dictate the consultation note as the patient puts their coat back on, and the referral letter before you call the next one in. Transcription runs on your own computer. With text insertion turned on, the transcript is typed into the field you had open in the patient record.
Appointments run back to back, and each one leaves something in writing. Some of it can wait until the evening. Some of it cannot.
Consultation notes
History, examination, assessment and plan, in the patient record. You write them while the patient gets dressed or just after they leave, and they are what you, or a locum, will read at the next appointment.
Referral letters
For cardiology, dermatology or the medical team on call: the reason for referral, the history, current medication and the question you want answered. Best written while the examination is still fresh, before the next patient comes in.
Letters and reports for patients
Fitness to take part in a sport, a letter for work or school, a report an insurer has asked for. A few lines, often requested as the patient stands up to leave, and read closely because they carry your name.
Medical summaries
Past history, allergies, medication and ongoing care, brought up to date for a patient with a long-term condition, before a hospital admission or for a colleague taking over. Longer than everything else, and often pushed to the end of the week.
Home visit notes
The examination happens in the patient's home, usually with no computer, and gets written up back at the surgery. After three or four visits, the details of the first start to blur into the last.
Day to day
Where the writing falls behind
Typing the note in front of the patient
Today
You type the examination while the patient waits, and you look at them less than you would like. Or you jot down three words and finish the note in the evening, when the details have merged with the rest of the day.
With Dictadoc
Start by switching on the dictation key and text insertion in the settings. With the record open, press the key, dictate the examination and the plan, then press it again. Once transcribed, the text lands where you left the cursor.
Dictation key
Text typed into the field
A letter interrupted by the phone
Today
You start the referral letter to cardiology and the phone rings: a pharmacist has a question about a prescription. When you get back to the letter, you look for where you stopped, and the next patient is already in the waiting room.
With Dictadoc
Switch the floating panel on. It stays on top of your clinical system and holds the buttons to start, pause and send a dictation. Pause to take the call, then carry on in the same report. The panel never takes the keyboard, so your cursor stays in the letter.
Floating panel
Dictation in several takes
Values to retype as figures
Today
Weight, blood results and doses come back from a dictation spelled out in words, or half in words and half in figures. You retype each value by hand so it can be read at a glance at the next review.
With Dictadoc
With "Numbers, units and dosages" turned on, a value dictated with its unit is written in figures: "eighty-six kilograms" becomes "86 kg", and "five hundred milligrams three times a day" becomes "500 mg, 3 times a day". Dictadoc does not check the dose. Reviewing it is still your job.
Numbers, units and dosages
Dictation example
A diabetes review, dictated into the record
Annual review for a patient with type 2 diabetes, dictated at the end of the appointment.
What you say
Annual diabetes review [full stop] no new symptoms and no hypoglycaemic episodes [full stop] taking medication as prescribed [full stop] weight eighty-six kilograms [comma] down from the last review [full stop] blood pressure at target on home readings [full stop][new paragraph] bloods reviewed [colon] creatinine eighty-four micromoles per litre [comma] potassium four point six millimoles per litre [full stop] foot check normal [comma] monofilament sensation intact in both feet [full stop][new paragraph] continue metformin five hundred milligrams three times a day [full stop] repeat prescription issued for three months [full stop] review with bloods in six months [full stop]
What Dictadoc writes
Annual diabetes review. No new symptoms and no hypoglycaemic episodes. Taking medication as prescribed. Weight 86 kg, down from the last review. Blood pressure at target on home readings.
Bloods reviewed: creatinine 84 µmol/L, potassium 4.6 mmol/L. Foot check normal, monofilament sensation intact in both feet.
Continue metformin 500 mg, 3 times a day. Repeat prescription issued for three months. Review with bloods in six months.
The words in brackets are commands. Dictadoc replaces them with punctuation and line breaks.
With the "Numbers, units and dosages" setting turned on.
The settings list every command for your language.
Privacy
What you dictate stays on your computer
Transcribed on your computer
Your computer transcribes your voice itself. Nothing you dictate is sent over the internet.
Erased on quit, if you want
Choose to keep nothing, and reports and recordings are erased when you quit Dictadoc.
Encrypted on your disk
The reports you keep stay in an encrypted database whose key is held by your system keychain.
For a group practice
Dictadoc Server transcribes for every workstation in the practice from one computer. Workstations need neither a graphics card nor internet access.
Can Dictadoc write the note from my conversation with the patient?
No. Dictadoc transcribes your dictation, not the consultation. It cannot tell one voice from another and does not write a note from a conversation. Once the examination is over, you dictate the note yourself, in a few sentences.
Are drug names spelled correctly?
Always check them. Dictadoc's drug lists work only when you dictate in French. In English, a word the engine hesitated over is matched against a general medical vocabulary, and words it heard clearly are left alone. Add the drugs you prescribe most to your vocabulary, written as they must appear, and every report after that uses your spelling. Dictadoc does not check doses or interactions.
Are blood pressure and temperature written as figures?
Not always. "Numbers, units and dosages" only changes numbers followed by a unit: "one hundred and thirty millimetres of mercury" becomes "130 mmHg". A blood pressure dictated as "one thirty-eight over eighty-two", with no unit, is left as it was transcribed. The same goes for a temperature in degrees and for the heart rate.
Can I dictate on home visits?
Only if you take a laptop, because Dictadoc does not run on a phone. On your rounds, record your notes on your phone or a dictaphone instead. Back at the surgery, drop the files onto a report and they are transcribed one after the other. MP3, M4A, WMA, FLAC, AIFF and WAV are accepted, depending on what your computer can read.
Can I dictate a medical summary over several days?
Yes. Each part you dictate is added to the same report as a take: past history one evening, medication the next. By default, reports stay encrypted on this computer, and the list sorts them by day and lets you search by title.
Install the app on Mac or Windows, buy a licence, then enter the key you receive by email in Dictadoc. The licence year starts on the day you activate it.
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