This dictation system is provided to you for the clinical documentation for the patient record required for each hospital visit. Follow-up letters i.e. to the Ministry of Transport, to whom it may concern, evaluations, referral requests, etc. are administrative correspondence and consequently are outside of Health Records responsibility for processing.
You must have your own personal and confidential dictating User ID number. Please call LHSC ext. 35131 or SJHC ext. 65584 to obtain your personal dictating number. These numbers must remain confidential and not shared with others. You can use your dictating number at all sites across the city.
DICTATING INSTRUCTIONS
1. Dial extension 66080 or 519-646-6080 from outside the hospital
2. Enter your 5 digit User ID number
3. OPTIONALLY you may be prompted for a Profile ID followed by:
#key:1 if dictating at RMH; 2 For all other sites
4. Enter the hospital site code followed by # key (It is important to select the correct site code to ensure that your note posts correctly in PowerChart)
1 University Hospital
2 Victoria Hospital
3 St. Joseph’s Hospital
4 Parkwood Hospital
5 LRCP
6 RMHC - London
7 RMHC - St. Thomas
5. Enter the work type followed by # key (It is important to select the correct site code to ensure that your note posts correctly in PowerChart)
6. OPTIONALLY you may be prompted for a RMH Unit (if you entered 1 for the Profile ID in step 3) followed by #key:
1 Assessment-L 2 Assessment-S
3 Mood&Anx-L 4 Mood&Anx-S
5 Psychosis-L 6 Psychosis-S
7 Geriatric-L 8 Adolescent-L
9 DDP-L 10 Concurrent Dis-L
11 Forensics-S
Note: It is important to select the correct worktype to ensure that your note posts correctly in PowerChart.
Site Specific Worktypes
University Hospital / Victoria Hospital
80 Clinic Report
81 Adult Psychiatry Note
82 Child/Adolescent Psychiatry
83 Women’s Health Clinic Note
84 Trauma Resuscitation Note
85 Trauma Clinic Note
86 Speech Language Pathology Note
87 Urgent Neurology Clinic Report
88 John H. Kreeft Headache Clinic
89 General Medicine Clinic Note
90 Geriatric Mental Health
91 TIA Clinic Note
92 Thoracic Surgery Clinic Note
93 In-hospital Transfer Note
St. Joseph’s Hospital
42 SJH Clinic Note
43 HULC Clinic Note
44 OB / GYN Clinic Note
London Regional Cancer Program (LRCP)
70 Radiation Treatment
71 Letter
72 Social Work
73 GYN Snap Shot
74 Ovarian Progress
75 LRCP Clinic Note
Regional Mental Health Care (RMHC) - London and St. Thomas
60 Assessment Report
61 Review Board Summary
62 Miscellaneous Note
63 RMHC Clinic Note
64 Letters (does not post to PowerChart)
7. Enter the PIN (Medical Record Number) followed by # key
8. Enter 2 to begin dictation: Dictate and spell patient’s name, PIN (Medical Record Number), your name and required copies (indicate address for out-of-town providers.
Keypad Functions:
2 To begin or resume dictating
3 To replay dictation
4 Continuous forward
44 Fast forward to end of report
5 To end last report and dictation session
6 Priority dictation (Use only for dictation that requires immediate transcription eg follow-up within 24 - 48 hours, patient being transferred to another facility, etc.)
7 Continuous rewind
77 Go to beginning of dictation
8 Go to next report
0 To open / interrupt report that cannot be finished during the current dictation session. When beginning a new session and after entering the site code, you will hear “you have an open report”. To retrieve it, enter 1 and continue to dictate. To ignore it, enter 2.
Guidelines for Dictating
1. Speak clearly, concisely and spell difficult or unusual words or medications.
2. State patient’s name (spell surname) and date seen
3. State your name and title (spell surname) and that of the attending physician.
4. State copies to relevant physicians (spell surname, state address if out of town)
Discharge Summary
1. Dates of Admission and Discharge
2. Discharge Diagnoses (Most Responsible, Pre and Post Comorbidities)
3. Operations / Procedures
4. Brief history of Current Illness
5. Course in Hospital
6. Condition on Discharge
7. Discharge Medications
8. Discharge Instructions
Operative Report
1. Date of Operation
2. Doctors in Attendance
3. Anaesthetist in Attendance
4. Pre-Operative Diagnosis
5. Post-Operative Diagnosis
6. Name of Operation(s) Performed
7. Description of Operative Procedure/Findings
Note: for St. Joseph’s Hospital, if you require a copy of the operative report, you must come to Health Records and fill out a form.
Clinic Notes
1. Date of Clinic visit
2. Clinic visit details and findings
3. Diagnosis
Consultation Note
1. Date of Consultation
2. Patient ID and reason for referral
3. History of presenting illness
4. Relevant past medical history
5. Current medications & medication allergies
6. Family and social history
7. Physical examination
8. Investigations to date
9. Impression and Plan/Recommendations
10. Prescriptions & follow-up
