Dictation of the discharge resumé: a forgotten link between the spoken and written word.
All medical personnel use jargon when conversing about patients. Such jargon can be clarified by questions asked at the moment of discussion. The reader of a discharge summary, however, does not have the option of questioning the author if meanings are ambiguous and vague. Editing discharge summaries is an impossible task--I've tried it and quit, partly from laughing, partly from crying, and mostly because the head record librarian refused to have all the summaries retyped. Save time in the record room by being more concise and clear in your dictation, then use the time you have saved for more rewarding activities. Organize your thoughts, dictate, then go smell the flowers with the recovered time.
Manning
R T
RT
University of Kansas School of Medicine, Wichita 67214.
D004282:Documentation; D005568:Forms and Records Control / Q000592:standards; D006801:Humans; D007802:Language; D008499:Medical Records / Q000592:standards*; D010351:Patient Discharge; D014956:Writing