Health Information
Management
Provincial Operations
Dictation/Speech/Transcription
(DST)
AHS eScription
2015 CLINICAL CLERK ORIENTATION
University of Calgary
UCMG Transcription
Services
What is the Purpose of the Health Record?
– To serve as a basis for planning patient care and for continuity in the evaluation
of the patient’s condition and treatment
– To furnish documentary evidence of the course of the patient’s clinical
evaluation, treatment, and change in condition during the hospital stay
– To document communication between the practitioner responsible for the
patient and other health care professionals who contribute to the patient’s care
– To assist in protecting the legal interest of the patient, Alberta Health Services
and the practitioner responsible for the patient
– To provide accurate and comprehensive data for use in continuing education,
planning, research and financial purposes
DST Contact and Hours of Operation
MTs transcribe:
•
Monday to Friday – 7 AM to 8 PM
•
Saturday to Sunday and statutory holidays 8:00 AM to 4:15 PM
DST Hotline: 1-844-944-3099
•
Help with speaker code
•
Help with accessing system
•
STAT/Priority report request
or
UCMG Contact and Hours of Operation
For Support Contact:
Phone: 403-592-5200
Fax: 403-270-0805
Email:
[email protected]
Hours of Operation: Transcription/Hotline
Monday – Friday: 7 AM – 4:00 PM
After Hours/Weekends:
[email protected]
AHS DST and UCMG eScription
Please note that even though you use the same speaker codes for AHS eScription and UCMG eScription, the systems are not the same. AHS and UCMG have two separateeScription systems and dictation cannot be transferred between the two systems. Failure to correctly access and dictate on the UCMG or AHS DST platforms, as outlined below, will result in you being required to re-dictate your reports into the correct system – to clarify:
• UCMG eScription system– when you are dictating as a UCMG clinical clerk from a UCMG outpatient clinic, you must dictate into the UCMG eScription dictation system as per UCMG eScription system dictation instructions. Please direct any UCMG eScription system questions to
• AHS DST eScription system– when you are dictating on behalf of an attending within Calgary zone or Cancer Control you mustdictate on the AHS DST system as per DST Resource Link http://goo.gl/ioIfpE. Please direct any AHS DST eScription questions to the DST Hotline1-844-944-3099.
For dictation to be considered within scope for AHS DST, there must be a valid encounter at an AHS facility for the report to be transcribed under. In-scope dictation for AHS eScription includes:
• Cancer Control • Calgary Zone
» Urgent Care/ER patients
» inpatients reports including inpatient consults, discharge summaries, ORs » operative reports for outpatient/inpatient/day surgery
» Preadmission Clinic (PAC)
» pediatric patients (including outpatient)
IMPORTANT – Please check with the attending physician BEFORE dictating from a Calgary zone adult outpatient clinical location on the AHS DST system. Very few adult outpatient clinics are supported by AHS DST. Many of these clinics are supported by UCMG Transcription Services, and others have their own internal transcription resources. Please note that using the incorrect system may result in lost dictation and the need to re-dictate on the correct system so that the reports are distributed correctly to support patient care.
ACCESS TO THE UCMG ESCRIPTION SYSTEM
The UCMG eScription system (403-220-7132) is for UCMG member physicians’ outpatient clinic
dictations. All adult outpatient work dictated from the UCMG outpatient clinics should be
dictated using the UCMG eScription System. How do you know which system to use?
UCMG eScription
AHS DST eScription
Is the patient in hospital now?
NO – use UCMG
Is the patient in hospital now?
YES – use AHS DST
Is your preceptor a UCMG member?
YES – use UCMG
Is your preceptor a UCMG member?
NO – Please check with your
preceptor/clinic manager for
instructions on non-inpatient dictation.
Before beginning to dictate determine which system you should be using to
complete your dictation.
If you are in doubt, ask your preceptor.
DST - Training
You will have reviewer
access to the reports
that you dictate. An 8-minute eLearning module
is available on the web with resources (see link
at the bottom of this slide) on keypad prompts,
facility codes, work types, workflow, and
eSignature features.
DST Repository & eLearning URL:
http://goo.gl/EGTgZ9
Quick References (PDF)
• eSignature Overview
• Desktop Login and Sign
• Save URL to Favourites
DST System Access & Keypad Prompts
End/Start Multiple Dictations
71 new dictation, different facility
78 new dictation, same work type
6
new dictation, same facility
8
new dictation, same patient
SYSTEM ACCESS
• dial 1-855-648-3117 to access the dictation system • enter your speaker code, then press #
• enter the facility code, then press # • enter the work type, then press #
• enter the medical record number (MRN) then press # • press 2 to begin dictating
• press 0 for your Confirmation ID
• Press 9 to end your report
KEYPAD PROMPTS
1 priority– when a report is required on an emergent basis press #1 at any time during the dictation
2 dictate -record/pause/resume after pause 3 incremental rewind and playback
4 rewind to beginning of report 54 incremental fast forward 55 fast forward to end of report
0 play confirmation # or receive confirmation #
9 end report: end dictation, receive confirmation #, and log out of system
*
clear entryif pressed before the #, this will clear the field of info entered by the user if an error has been made, i.e., clears speaker code, facility id, work type, or MRNDST Facility Codes
Calgary Zone
191 Alberta Children’s Hospital 198 Canmore General Hospital 172 Child Development Centre
187 Claresholm Centre for Mental Health & Addictions 181 Claresholm General Hospital
197 Didsbury District Health Services 192 Foothills Medical Centre
173 High River Hospital 185 Oilfields General Hospital 193 Peter Lougheed Centre
190 Richmond Road Diagnostic & Treatment Centre 194 Rockyview General Hospital
195 Sheldon M Chumir Health Centre 180 South Calgary Health Centre 175 South Health Campus
186 Southern Alberta Forensic Psychiatry Centre 196 Strathmore District Health Services
183 Vulcan Community Health Centre 182 Willow Creek Continuing Care Covenant
788 Banff Mineral Springs Hospital
Cancer Control
205 Barrhead Community Cancer Centre 206 Bonnyville Community Cancer Centre 219 Bow Valley Cancer Centre
207 Camrose Community Cancer Centre 217 Central Alberta Cancer Centre 200 Cross Cancer Institute
208 Drayton Valley Community Cancer Centre 203 Drumheller Cancer Centre
209 Fort McMurray Cancer Centre 218 Grande Prairie Cancer Centre 204 High River Cancer Centre
210 Hinton Community Cancer Centre 201 Holy Cross Cancer Centre
214 Jack Ady Cancer Centre (Lethbridge) 211 Lloydminster Community Cancer Centre 215 Medicine Hat Margery E Yuill Cancer Centre 212 Peace River Community Cancer Centre 202 Stollery Childrens Cancer Centre 213 Tom Baker Cancer Centre
Please reference the below link
for all updated DST resource
information:
DST Work Types
Please reference the below
link for all updated DST
resource information:
DST - Distribution of Reports
• first and last name of all copy recipients must be clearly stated at
the time of dictation or the copy will not be sent as requested.
• all reports will be transcribed or edited by a medical
transcriptionist
• upon completion of transcription reports are distributed
before
signature by the attending physician:
o
reports will be electronically distributed to Netcare and SCM (urban)
o
health records copy will be printed
o
authoring providers and courtesy copies will be distributed by fax or
mail out, based on current practice
• edits made on reports at the time of review or eSignature will be
redistributed
Most Responsible Diagnosis (MRD)
The MRD is required for each discharge summary.
The MRD is a single diagnosis or condition that consumed the greatest portion of
the length of stay or the greatest use of resources (i.e. OR time, investigate
technology, etc).
Comorbidities:
A condition(s) that coexists at the time of admission or develops
following admission:
significantly affects the treatment received
or
requires treatment beyond maintenance of the pre-existing condition
or
REQUIRED PATIENT INFORMATION FOR DATA COLLECTION
Clinical Documentation – Guidelines
• Most Responsible Diagnosis (MRDx):Document SINGLE diagnosis/condition that had greatest impact on length of stay • Diabetes Mellitus (DM):Document Type 1 or Type 2 (Avoid terms: NIDDM; IDDM or Borderline)
• Diabetes Mellitus with Hyperglycemia: Document if DM is out of control • Infections:Document Specific Organism, if known
• SIRS:Specify if Infectious or Non-infectious origin • Sepsis:Specify if Localized OR Systemic
• Drug Resistance Organism: Specify if Resistance vs. Carrier Status • Pneumonia:Document Specific Organism and COPD if known • Pneumonia Type:Lobar vs. Bronchopneumonia vs. Aspiration
• Flagged Interventions:Document Chest tube & CVC line insertions; Paracentesis / Thoracentesis, TPN, CPR, if applicable • Hgb:Specify Anemia in documentation
• Symptom Condition:Document to the Diagnosis if known
• Chronic Renal Failure (CRF):Indicate Stage of CRF (1 to 5 or ESRD)
• Hypertension (HTN):Document “due to” or “hypertensive” if linked to a cardiac or renal condition • ALL Cardiovascular diseases:Document Hypertension if known
• Asthma:Specify “childhood asthma” if known
• Dehydration:Document if IV fluids used in treatment of condition
• Post-Intervention condition:Clearly document the condition as “Post-op” • Palliative Patient:Document if patient “Palliative” on admission
Dictated reports containing personal health information of patients copied to third party/non‐healthcare
providers, such as schools, daycare centres, lawyers, insurance companies, etc., are
not
distributed through
the dictation systems.
•
As per the Health Information Act, a valid written consent signed by the patient/legal guardian must be
obtained prior to such a disclosure.
•
It is the responsibility of the physician/allied health professional to confirm that the parent(s) receiving
the information is the legal guardian.
– Consent to Disclose Health or Personal Information form (#01551) must be completed prior to
disclosure
– Consent form must then be forwarded to Health Information Management for processing when the
patient chart is managed by Health Information Management.
Clinical areas that manage their own records may process the request once consent has been
obtained, however, prior to any disclosure, the record must be reviewed for severing as per
section 7(2) of the Act.
– Dictating physician or allied health professional states that written consent has been obtained and
placed on the chart.
Consent form must still be directed to Health Information Management, Release of
Information where the information will be reviewed and processed.
•
Due to risk of security breach, copies of patient care documentation will not be distributed if
clear/complete information for the copy recipient is not given at the time of dictation. Best practice to
follow when requesting copies is to state and spell the care provider’s
complete
first and last name, city,
and specialty. Dictate full mailing address for out‐of‐province care providers.
www.ucalgary.ca
COPIES OF DICTATED PATIENT CARE DOCUMENTS TO
THIRD PARTY/NON-HEALTHCARE PROVIDERS
UCMG eScription - DIAL: 403-220-7132
Enter your speaker code followed by #
All UCMG Member Physicians and Trainees must use their uniquely assigned Speaker Code. Codes may notbe shared.
Enter the 5-digit Clinic Code followed by #
Enter the patient MRN number followed #. No MRN? Use 999999.
Press 2 to begin Dictation of Report.
Press 0 for your Confirmation Number
Dictate – clearly state & spell:
Your full name.
Clinic name and Location (site)
Patient name, date of birth , MRN
Clinic Date
Copy Distribution – please state full name and location of all recipients
Press 9 to end dictation and receive confirmation number
CONFIRMATION NUMBER - the confirmation # is your receipt of dictation. Please record this number for future reference.
UCMG eScription Clinic Codes
Double click PDF icon for complete list of UCMG Clinic Codes
UCMG CLINIC CODES
All UCMG EScription reports are in the form of a letter. Clinic Codes are
used to design the letterhead. You will be prompted to enter an
appropriate code when you dictate. Clinic codes are posted in each
facility, but if you are unsure – ask your preceptor. A full listing of clinic
codes will be emailed to you upon request.
ACH – all codes start with 224
22409 – Cardiology
22412 – Ear, Nose , Throat
22410 – Neurology
22401 – Neuromotor
FMC – all codes start with 362
36201 – Addiction Centre
36202 – Adult Cystic Fibrosis
36206 – Arrhythmia
36219 – Gastroenterology
There are currently over 50 clinic codes based in 13 different facilities. The above is a
sampling only.
An up-to-date list and other useful information is available at:
http://cumming.ucalgary.ca/UCMG_eScription
1. Go to
www.escription.ca
2. Enter UCMG as the
CUSTOMER LOGIN
3. Enter your User Name (speaker code) and password
4. At the EditScript Online screen click on Clinicians and then on eSignature
5. Change your password as requested
6. Click on Clinicians again, and choose eSignature.
USING NETSCRIPT TO REVIEW AND
AUTHENTICATE YOUR DOCUMENTS:
Editing Tip:
Do not use special characters or symbols such as #@*&^ or ~. These
characters will prevent your report from uploading to SCM and Netcare.
www.ucalgary.ca
•
By default, the check boxes selecting all
reports are marked.
•
Select View/Sign button to open the reports.
(Reports with check boxes selected will be
brought forward for viewing.)
•
A
New Dictation
view will result
•
The Clinician can now review the transcribed
report and complete various actions and/or
activities.
•
Select
Save & Sign
button to move the report
forward into the Distribution process.
Retrieving a Patient Report on Netscript for Review
A table of transcribed reports awaiting your approval will be visible
Once a patient’s medical report is
Saved & Signed
it is considered complete and is automatically sent
into the distribution process, including uploads to SCM and Netcare.
If the medical report has any errors or omissions it can only be updated or corrected through a formal
“Cancel” process requiring the signing Clinician/Preceptor to contact Transcription Services and once
edited will require repeating the Clinician Approval (eSignature) process.
Dictation Best Practices
Concise wording describing the condition(s) and
intervention(s) are essential to patient care
documentation.
If it is not dictated then it cannot be transcribed on the patient’s report;
therefore, it did not happen.
Dictation Best Practices Tool Kit
http://www.ahdionline.org/ProfessionalPractices/ToolKit
s/DictationBestPractices/tabid/270/Default.aspx
AT THE BEGINNING OF EACH REPORT THAT YOU
DICTATE, PLEASE . . .
•
Clearly state then spell your first and last name.
•
Clearly state then spell the attending physician's first and last name.
•
Clearly state ALL patient demographics:
–
MRN
–
site
–
state then spell the patient’s first and last name
–
date of birth & age
–
gender
•
Clearly state the date you are seeing the patient:
–
date of procedure
–
date of consult
–
date of admission & date of discharge
–
date of delivery
•
Clearly state and spell the first and last names of all copy recipients
(i.e., referring or family
physicians that you require copies of the report to be distributed to).
If you do not clearly identify
who you want the copy to be sent to, the care provider will need to contact HIM, Release of
Information to request a copy for their chart.
Computers do not think – they cannot reason, and
unfortunately the software hears what it hears. They cannot
reason out that the drug it just spit out onto the page is the
wrong medication or dosage. They cannot think if it did not
quite hear the word “not” so it left it out. The person’s medical
history is now irrevocably changed and without the slightest
bit of guilt because it was done by a machine.
Speech recognition requires that you be well organized and unambiguous in your
dictation style. Have your speaker code, clinic code, and regional health numbers
readily at hand. After dictating your report note the confirmation number on your
handwritten notes and give those notes to your preceptor or place them in the clinic
chart.
Letter writing/dictation, like any other skill in
medicine, requires practice as well as constructive
criticism. In most cases your preceptor will look over
your transcribed letter, make some suggestions and
give the letter back to you.
Before you dial in to dictate . . .
• Be organized – ensure you have all patient care documentation organized before you access the dictation system. If you do not dictate the information we cannot include it in the patient care documentation.
• Ensure that you set aside enough time to complete your dictation (i.e., do not rushing through the dictation). • Please do not eat, chew gum/candy, etc., while dictating – it is very hard for the transcriptionists to understand
what you are saying when you are chewing and trying to dictate.
• TOCANCEL A DICTATION: Please do not just hang up in the middle of a dictation and re-dictate the report. Please ensure that you call the appropriate area to cancel the dictation.
TO CANCEL:
You called 1-855-648-3117 AHS DST eScription –CALL DST Hotline 1-844-944-3099
You called 403-220-7132 UCMG eScription –CALL 403-592-5200
We understand that you are learning how to use the dictation system and may intermittently need to cancel a dictation – ensure that you call us immediately when this happens so that we can pull your report out of the system so that it is not at risk of being transcribed.
• Confirmation ID = RECEIPT FOR DICTATION: Always note the confirmation ID for all of your reports so that you can state the confirmation ID and patient’s MRN if you need to call to request a cancelation or to prioritize your dictated report.
• The dictation system instructions have been put together to help ensure that you can complete your patient care documentation efficiently. Our areas cannot run efficiently and meet expected turnaround times when
instructions are not followed. When instructions are not followed this causes a decrease in productivity, impacts the turnaround times for all dictated reports and may result in incomplete/deficient documentation which does impact patient care.
• NEVER share your speaker code with another user. Your speaker code specifically identifies you as the author of the dictated report.
