Dictate the initial assessment between two patients and the discharge report when you have a moment. Dictadoc transcribes on your computer and double-checks the musculoskeletal words it did not catch clearly.
From the first appointment to discharge, each patient leaves a trail of documents. You write them between patients, on a list where appointments follow each other closely.
Initial assessment
Subjective history, pain, range of movement, strength, function and goals, at the start of treatment. It is the longest document, and it often gets written up after the last patient, from measurements jotted on paper during the session.
Treatment notes
A few lines per session: what you did, how the patient tolerated it, what has changed. Short but numerous, they get written in the minutes between patients and pile up when the list is full.
Discharge report
Progress since the initial assessment, outcomes and advice for what comes next, for the GP or consultant who referred the patient. It goes back to the measurements of the first assessment to compare them.
Home exercise programme
The exercises, with sets, repetitions and instructions, that the patient takes home after a session. A short list, but one you rewrite at every stage of rehab.
Day to day
What slows your assessments down
Joint terms spelled wrong
Today
A general-purpose dictation tool can trip over musculoskeletal terms: tenosynovitis, patellofemoral, acromioclavicular. They come up again and again in an assessment, and each mistake has to be fixed by hand before the report goes out.
With Dictadoc
Words the engine did not hear clearly are compared with a medical vocabulary built around the musculoskeletal system: foot and ankle, knee, hip and spine, shoulder and upper limb. Words it heard without hesitation stay exactly as you dictated them.
Medical vocabulary check
Measurements on paper, written up hours later
Today
Appointments come every half hour, and two patients are sometimes working in the gym at once. The measurements stay on a sheet of paper, and the write-up happens in the evening, when you have to remember what each abbreviation meant.
With Dictadoc
Dictate the assessment in several takes: the examination as soon as the patient leaves, the goals at the next gap. If someone needs you, pause and resume once you are free. You can play back each take and fix a misheard word with the keyboard.
Dictation in several takes
A report to lay out again
Today
You send the discharge report from your word processor, on headed paper. Text brought over from a dictation tool often lands as a single block, and you rebuild the paragraphs and the exercise list yourself.
With Dictadoc
Copy the report from Dictadoc and paste it into Word or the body of an email: the paragraphs and lists come with it. Add your letterhead and signature as usual, without redoing the layout.
Copy to Word
Dictation example
A knee review, dictated after the session
Patient seen six weeks after an anterior cruciate ligament reconstruction.
What you say
Right ACL reconstruction [comma] six weeks post-op [full stop][new paragraph] walking without crutches [comma] slight limp at the end of the day [full stop] minimal effusion [comma] scar healed and mobile [full stop] full extension [comma] active flexion still limited [full stop] quadriceps wasting with thigh circumference two centimetres less than the left [full stop] single leg stance held but unsteady [full stop][new paragraph] goals [colon] regain flexion [comma] strengthen the quadriceps and work on proprioception [full stop][new line] home exercise programme given to the patient [full stop]
What Dictadoc writes
Right ACL reconstruction, six weeks post-op.
Walking without crutches, slight limp at the end of the day. Minimal effusion, scar healed and mobile. Full extension, active flexion still limited. Quadriceps wasting with thigh circumference 2 cm less than the left. Single leg stance held but unsteady.
Goals: regain flexion, strengthen the quadriceps and work on proprioception.
Home exercise programme given to the patient.
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.
Partly. The list holds about 250 terms, for the foot and ankle, knee, hip and spine, shoulder and upper limb, examination and imaging. Respiratory physiotherapy and pelvic health are not on it, so add the terms you need to your own vocabulary, from the settings or with a right-click in a report.
Are joint ranges written as figures?
Not in degrees. "Numbers, units and dosages" converts numbers followed by a unit, so "two centimetres" becomes "2 cm". Degrees are not one of those units: "one hundred and ten degrees" stays in words, and so does a muscle grade such as "four out of five".
Can I dictate while I am treating a patient?
Dictadoc is not controlled by voice, apart from punctuation. A dictation starts and is sent with a click, or with a key if you have chosen one. Dictate just after the session instead, while the examination is still in your head.
Can I send the report to the GP from Dictadoc?
No. Dictadoc does not send anything and does not create PDF or Word files. Paste the report into your word processor or your email, where its paragraphs stay in place, and send it the way you do today.
How do I dictate a home exercise programme?
Say "new line" after each exercise, and each one goes on its own line. When "Numbers, units and dosages" is active, "exercises three times a day" is written "exercises 3 times a day". Sets and repetitions have no unit, so "three sets of ten repetitions" stays in words.
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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