Voice dictation for physicians in internal medicine
Dictate the discharge summary as the results come in, and the clinic letter that goes to the GP with copies to other teams. Dictadoc transcribes on your computer, can lay the text out in paragraphs and keeps its formatting when you copy it.
In internal medicine, a patient often arrives with several problems, a long drug chart and more than one consultant. Every document has to make sense to a colleague who has never seen the notes.
The discharge summary
Presenting complaint, background, investigations, progress problem by problem, medication on discharge and follow-up. Several pages after a long admission, due on the day the patient leaves, often with results still pending.
The admission clerking
A long past medical history, a long drug history, the story of the illness and a full examination. It is written on admission, sometimes late in the evening, and the rest of the stay is built on it.
The clinic letter
The work-up of a prolonged fever, an abnormal blood result or a systemic disease, with the differential and the tests requested. It goes to the GP, copied to the specialists who already see the patient.
The ambulatory care note
An infusion, a planned set of investigations or a treatment review. Each note is short, but a single day brings a great many of them.
Day to day
What weighs down your summaries
Several pages in a single block
Today
The discharge summary for a patient with multiple conditions covers the background, every problem during the stay, bloods, imaging and discharge medication. Dictated in one go, it comes back as a wall of text that you split up by hand.
With Dictadoc
Dictadoc can lay the summary out in paragraphs. By default the breaks follow what you dictate, such as "new paragraph", with no AI and nothing to download. An optional model installed on the computer can also choose the breaks itself, without ever rewriting a word.
Paragraph layout
A summary that builds up over the whole admission
Today
Results arrive over several days: an autoimmune screen, a biopsy, opinions from other teams. The summary waits for discharge, and by then one or two weeks of admission have to be pieced together from scattered notes.
With Dictadoc
Dictate the summary in several takes as the results come in. Reports are kept by default, so it waits for you from one day to the next, encrypted on the disk with a key held by the system keychain. Each take keeps its recording, so you can listen again before reading the summary through.
Dictation in several takes
Encrypted retention
The letter loses its formatting when pasted
Today
The clinic letter goes to the GP and to several specialists, from a word processor or by email. Pasted as plain text, it arrives with extra blank lines and a medication list you have to rebuild.
With Dictadoc
Copy the report in one click, then paste it into Word or your email. The paragraphs and lists arrive just as you checked them in Dictadoc.
Copy to Word
Dictation example
Part of a discharge summary
Summary of an admission for giant cell arteritis.
What you say
Admitted with new temporal headaches [comma] jaw claudication and weight loss [full stop][new paragraph] admission bloods showed a CRP of ninety-five milligrams per litre and a haemoglobin of one hundred and eight grams per litre [comma] with normal renal function [full stop][new line] temporal artery biopsy consistent with giant cell arteritis [full stop][new line] PET-CT showed no large-vessel involvement [full stop][new paragraph] diagnosis [colon] giant cell arteritis without large-vessel involvement [full stop] started on prednisolone forty milligrams once daily [comma] with calcium and vitamin D and a proton pump inhibitor [full stop][new line] follow-up in the vasculitis clinic in four weeks [full stop]
What Dictadoc writes
Admitted with new temporal headaches, jaw claudication and weight loss.
Admission bloods showed a CRP of 95 mg/L and a haemoglobin of 108 g/L, with normal renal function.
Temporal artery biopsy consistent with giant cell arteritis.
PET-CT showed no large-vessel involvement.
Diagnosis: giant cell arteritis without large-vessel involvement. Started on prednisolone 40 mg once daily, with calcium and vitamin D and a proton pump inhibitor.
Follow-up in the vasculitis clinic in four weeks.
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 clinic or hospital
Dictadoc Server transcribes for every workstation in your organisation, on a server on your premises. Nothing leaves your network.
Can Dictadoc summarise the admission or write the discharge summary?
No. No AI writes, summarises or rephrases what you dictate: the summary contains your words. The optional layout model only chooses where the paragraphs go. Dictadoc is not a medical device and checks neither a value nor a dose. You review everything.
Are blood results written as numbers?
Yes, when "Numbers, units and dosages" is on and a unit follows the number. "Seventy-four micromoles per litre" becomes "74 µmol/L" and "one hundred and eight grams per litre" becomes "108 g/L". A count dictated with no unit, such as platelets of two hundred and fifty, stays in words.
Does Dictadoc know rare diseases and their treatments?
It has no list of diseases, and its drug lists cover French dictation only. Words the engine is unsure of go through a general medical vocabulary, where rare diseases have no special place. When the name of a syndrome or a biologic comes out wrong, add it to your vocabulary, and Dictadoc writes it that way from then on.
Our electronic patient record opens in a browser. Can the text go there?
Yes, once you allow Dictadoc to write into the active application in the settings. The text goes into the field that had the cursor, whether the record is installed software or a page in your browser, with no connector. Some software refuses paste: switch to typing, and Dictadoc enters the text key by key.
A result comes back after discharge. Can I add it to the summary?
Yes. Find the report in the list by its title and dictate one more take for the result. Then copy the complete text into the record or the letter. Dictadoc does not change what has already been sent: the updated version goes out the usual way.
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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