Medical Notes: Dictation vs Transcription in Clinical Practice

In the medical field, accurate documentation is crucial for patient care and legal purposes. Two common methods of capturing medical information are dictation and transcription, each with its unique processes and benefits. While both aim to create precise records of medical notes, understanding their differences can help healthcare professionals choose the most effective approach for their needs. This blog will explore the key distinctions between dictation and transcription in the medical field, shedding light on their roles in modern medical practice.

Difference Between Dictation and Transcription

With a wide range of medical documentation tools available to healthcare providers, it can sometimes be difficult to keep track of how each one handles clinical documentation. To better understand this topic, it's important to first recognize the basic differences between dictation and transcription. Dictation involves speaking to another person or device, while transcription refers to the process of converting that spoken speech into written text. In simpler terms, dictation is the act of speaking, and transcription is the act of writing to create medical notes.

The connection between dictation and transcription has historically been strong, with both methods often used together in various fields such as science, law, history, and medicine. As technology has progressed, however, the close relationship between dictation and transcription has become less pronounced, with the lines between the two growing less distinct. This can be easily observed in today's medical field, where both dictation and transcription alleviate the workload linked with clinical documentation.

Dictation in the Healthcare

Understanding dictation as an action helps clarify its role in the medical field. With that in mind, there are two main ways medical dictation is employed to simplify documentation:

Dictation Recording

The dictation recording is typically done either during the patient’s visit or after the completion of visit in the absence of the patient. Many healthcare professionals believe that dictating while with the patient leads to better health outcomes and reduces burnout, but both methods are still commonly used.

In any scenario, it's important to consider that dictation should always be a meticulous process. Since dictation is intended to capture patient health information, not casual conversation, it depends on specific verbal cues and prompts from the provider to ensure accurate documentation. For example, after some initial greetings, a provider might ask the patient about the reason for their visit. After hearing the patient's account of their stomach pain, the clinicians may use the recording device and dictate: "Patient presents today with pain in the stomach." Once recorded, this dictated note will be transcribed into the patient’s HPI/subjective section. Similarly, the same sentence can be dictated once after the patient or client exits the doctor’s room or OPD of a hospital/clinic. Although this method may be less intrusive, dictating after the visit often depends more on memory, which can increase the risk of errors.

No matter how the provider chooses to dictate, this method serves as a classic example of dictation recording in healthcare and demonstrates the close relationship between dictation and transcription. However, with advancements in technology, this reliance is beginning to fade. We are now seeing more advanced dictation tools that also have transcription capabilities.

AI Dictation Software for Medical Note Generation

AI dictation software differs from traditional dictation as it utilizes speech and voice recognition to understand both the words and the meaning of the contents of conversation before creating medical notes. This allows the software to also handle the transcription, reducing the need for a human transcriptionist or detailed note-taking after the session. Furthermore, AI dictation software can often integrate with a provider’s electronic health record system, enabling it to not only interpret the dictation but also input it directly into the relevant fields of the EHR when directed properly.

After a patient visit, a healthcare provider can sit down and begin dictating the information gathered during the encounter, carefully guiding the dictation device to the appropriate sections of the EHR. For instance, using the same example of HPI recording as above, the provider might say: “Section one, subjective, History of Present Illness: Patient presents today with pain in his chest and stomach.”

As with any method, there are both advantages and drawbacks. While many providers prefer this approach over human medical transcriptionists, an equal or greater number find the technology difficult to use. This is mostly because AI dictation software requires a lot of careful, deliberate dictation. Providers must frequently pause and restart their notes as they move between different sections, and the technology also demands that they dictate all punctuation marks, such as commas and periods. Over time, some providers find this process mentally exhausting and eventually look for a less taxing alternative.

Medical Note Generation: Transcription in the Healthcare

We already know that transcription involves converting spoken words into written text. Traditionally, medical transcription is performed by human transcriptionists working for larger transcription services. These companies, although not bound by the same federal rules as individual healthcare providers or organizations, typically require their employees to have some level of medical training or relevant industry experience. This process ensures that any transcriptionist handling a specific dictation has the necessary knowledge of medical terms and language to create accurate medical notes.

Outsourcing transcription work allows healthcare providers to focus more on the patient during exams and appointments. Instead of typing notes into a notepad or directly into the EHR, they can engage with the patient and only pause to dictate important details into their recording device. Compared to traditional medical scribes, employing a medical transcriptionist or using a large transcription service can, in some cases, be safer and more secure. This is due to a phenomenon called functional creep, where trusted scribes might unintentionally take on tasks beyond their role, which can put providers at risk for malpractice. With medical transcriptionists, the relationship is more formal and regulated, reducing the likelihood of such issues.

However, there are still some significant drawbacks to using medical transcription. As discussed earlier, one issue is that transcribed documents can have long and sometimes unrealistic turnaround times, and the quality can vary greatly depending on the individual completing the transcription. Furthermore, transmitting sensitive patient information through unsecured channels can create malpractice risks for healthcare professionals. For those who dictate after patient visits, relying on memory can lead to inaccurate notes and poorer care quality.

SOAPsuds: AI Transcription for Note-Taking

At SOAPsuds, our comprehensive medical documentation solution features advanced AI transcription software that transforms your natural conversations with patients into accurate transcriptions. What sets SOAPsuds apart is that it does not require any specific prompts or intentional dictation. Our software leverages natural language processing to differentiate between casual conversation and clinically significant information, ensuring that the transcription focuses solely on relevant patient health details while creating a medical note. But that's just the beginning.

SOAPsuds: AI Scribe and Medical Note Generation

Unlike traditional medical dictation and transcription tools, SOAPsuds cutting-edge AI technology can extract the relevant information from a transcription and place it in the correct fields of a provider’s systems. With SOAPsuds, all a provider needs to do is talk to their patient as usual, and our technology captures the necessary details, generates a HIPAA-compliant SOAP note (customized to your templates and preferences), and then directly enters that note into your patient records.