Spectrum-Doctor Dictation Best Practices

Doctor Dictation

Best Practices

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About this presentation:

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Why choose dictation?

SpectrumEval strongly encourages you to dictate your reports— preferably within 24 hours after your evaluation. In our experience, dictation is the most comprehensive, fastest, and most efficient way to begin the process of building your QME report. This document serves as a guide for doctors to ensure clear and effective dictation of their notes.

Starting your Dictation

Please speak slowly and clearly throughout your dictation. Always begin with your full name, the patient's name, and the type and date of evaluation. Types of evaluation:

• QME
• Follow-up or re-evaluation
• Supplemental report

For supplemental reports, mention the date the request was received.

History Section

Under normal circumstances, you can find a complete history of the patient in your DRAFT report. We recommend you print a copy of the DRAFT to review the history with the patient. This includes: history of injury, history of treatment, current complaints, general medical history, subsequent injury, social history, permanent disability payments, and employment information. If any modifications should be made to any of these sections, include them in your dictation.

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Editing Information

If you intend to modify any completed section (mainly the History section), clearly specify the heading under which you are making changes (e.g., Current Complaints) before dictating the updated information.

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Header Identification

Before dictating, please identify the specific report heading or section you intend to address.

Physical Examination

Dictation

Your medical opinion regarding the following report headers is REQUIRED:

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Disability Status

The physical examination

Work Restrictions

Diagnostic Studies Requested

Apportionment (MMI)

Diagnostic impression

Causation

Treatment Recommendations (Not MMI)

Discussion/Summarization of the Case

Future Medical Care (MMI)

Don’t forget mention the corresponding headers when you are dictating your opinions.

State the header and provide any work restrictions/limitations that the patient should follow. AMA compliant templates regarding work restrictions might be applied to help you form your opinion. EXAMPLE:

Note the header and state whether the patient is at MMI or not. A standardized template might be applied to format this information. EXAMPLE:

Indicate whether the entire issue is related to the industrial injury by stating "NONE" or “100% to the industrial injury”. If previous or subsequent injuries are apportionable please specify the approximate apportionment attributed to prior conditions (e.g., degenerative disc disease or arthritis) or subsequent condition. Provide the appropriate percentage allocation. Example:

Identify this header in your dictation if you wish to express opinions or discuss the non-header specific issues related to the case. Adding a discussion to your med-legal report is recommended to summarize the case. Example:

It is recommended that you order any diagnostic studies that will assist you in making determinations regarding the claim. EXAMPLE

The examination sheets have been built compliant with the AMA Guides. Your findings in the physical examination are key to providing an accurate impairment rating once the patient has reached MMI. The examination sheets are ordered from top to bottom, depending on the claimed body parts, starting from the spine. When dictating, only note the abnormal findings for range of motion, sensory, strength, and any other specific tests. The examination sheets already include normal values. EXAMPLE 1: EXAMPLE 2:

Clearly state the causation by date of injury and body part. Briefly note why this is your opinion . A standardized template might be applied to format this information. EXAMPLE 1 Specific Injury: EXAMPLE 2 Cumulative Trauma:

Use this header if the patient is not MMI and requires further treatment. Outline the recommended treatment, including follow-ups, medications, physical therapy, diagnostic studies, or surgery as indicated. The treatment recommendation should be included to help the patient achieve maximal medical improvement. EXAMPLE:

Use this header if the patient is MMI. List any anticipated future medical care needs, including follow-up appointments, medications, physical therapy, diagnostic studies, or surgery. EXAMPLE:

After the examination, move on to the Diagnostic Impression section (limited to claimed industrially related body parts only). Remember to specify the header before listing the conditions. Progress systematically, beginning from the top, such as spine, shoulders, elbows, wrists/hands, and proceeding downward as relevant. EXAMPLE: