JHH DICTATION INSTRUCTIONS

You can use the JHH Dictation System to dictate discharge summaries and clinic notes,

using the following guidelines:

Dictate Instructions

Dial 955-9033, listen for voice prompts:

1. Enter 5 digit Doctor ID, then press #

2. Enter 2 digit Work Type, then press #

02 Addendum

92 Operative Report

30 Clinic Note

94 Discharge Summary

90 Stat

3. Enter 7 digit Patient History Number, then press #. Wait for the tone and begin your dictation. Once done, you can press *2 to get the dictated report number, which is often handy if you need future reference to that dictation.

Key Pad Functions

1 Listen/Play

2-1 Rewind/Autoplay

3 Fast forward to last word

4 Resume dictation

5 Pause

7 Rewind to beginning/Autoplay

0 Repeats Dr. ID only

Clinic Note Format

Your name, Patient name, History number (please spell names)

Visit date, Clinic number (141=housestaff at JHOC; 107=medicine clinic, e.g. Tindeco)

Attending physician or Primary Provider (you at the JHOC housestaff practice), Other physicians (please spell names)

Reason for visit (chief complaint)

History of present illness (may include past medical/surgical history, family history, social history, immunization history)

Medications

Allergies

Major Findings (including PE, pertinent laboratory/imaging study results)

Assessments

Problems/Diagnoses

Procedures and Immunizations

Plans

Medications Changes

CC list (include address of non-JHH doctors)

Note:

You need to finalize/sign your own clinic notes.

In EPR95, you will not receive a copy of the finalized note; therefore, you need to print it for yourself and anyone to whom you would like to send a copy.

Discharge Summary Format

Your name, Patient name, Admission and Discharge dates

Attending physician, other physicians (please spell names)

Condition on discharge

Diagnoses/Problems

Procedures

Brief history, Major findings, and Hospital Course (500 words or less)

Reportable diseases

Adverse drug reactions, Allergies, and Complications of procedures

Discharge medications

Discharge instructions: Diet, Activity, Other

Follow-up care

CC list (include address of non-JHH doctors; medical students often appreciate receiving a copy of the discharge summary)

BAYVIEW DICTATION INSTRUCTIONS

As a Unit Resident, you are responsible for dictating all discharge summaries of your patients. You can use your Hopkins MD number as the dictating 5-digit MD ID number, or call medical records for more specifics (0-0692). Then follow the guidelines below.

Dictate Instructions

Dial 550-0700, listen for voice prompts:

1. Enter 5 digit MD ID, then press #

2. Enter 1 digit Report Type, then press #

1 Operative Note

2 Discharge Summary

6 Stat (Let medical records (00692) know when you’re done)

3. Enter 7 digit Patient History Number, then press #

(if 6-digit Patient ID #, enter “0” as the first digit).

Wait for the tone and begin your dictation.

Key Pad Functions

1 Listen/Play

2 Dictate

3 Play back

4 Stop/Pause

Press 2 to resume dictation.

5 End document

6 Go to end

7 Fast forward

8 Go to beginning

9 Manual disconnect

Discharge Summary Format

Patient name, Age, Gender, History number (please spell names)

Admission and discharge date

Service (Cardiology, Pulmonary)

Intern, Resident, Fellow, Attending physician, Primary physician (please spell names)

Principal diagnoses, Reason for hospitalization

Other diagnoses

Principal procedures

Hospital course by active problems (Please be brief)

Condition of patient on discharge, Projected health status 1 month after discharge

Specific discharge plans: Medications, Activity limitations, Diet, Critical pending information, Follow-up appointments

CC list (include address if non-Bayview physicians)