RSNA: Top strategies for avoiding common dictation pitfalls

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 - unhappy doctor

CHICAGO—Radiology residents should understand the nuances of dictating complex cases and avoid common bad habits, according to a RSNA poster presentation.

Mark Mamlouk, MD, from the radiology department at the University of California, Irvine, explained that residencies do not provide much formal education for proper dictation techniques. Residents largely learn from those around them, and bad habits can be acquired.

For example, Mamlouk said vague comments or those that do not provide much value should be avoided. “The most notorious are ‘clinically correlate’ and ‘if clinically indicated’. While every radiologist knows these statements well, clinicians cringe when they read them and think we probably recite them in our sleep,” he said.

A common problem is not every case will come with an adequate clinical history. In the age of EMR, radiologists may spend more time looking up clinical histories, and Mamlouk advises that these histories should be billable and help lead to a proper diagnosis. “Sometimes in complex cases, more ownership is required of the radiologist to search out the clinical history or even call the clinician because it can be the difference between a wrong report and a right report, and ultimately that affects our patients.”

Patients increasingly have access to their radiology reports, and with more patient portals coming online, Mamlouk said the patient's reaction to what is being dictated should be taken into account within reason. Some common report phrasing could cause needless anxiety. The phrase “tumor not excluded,” for example, may be included on a report even when the radiologists is more than 90 percent certain a tumor isn’t present. In some cases, if a phrase like that can be eliminated without changing the overall impression of the report, it may better serve a patient audience.

The full presentation can be found in the Lakeside Learning Center under number LL-HPE3174 during the RSNA annual meeting.