Dictation

The Connect Care clinical information system (CIS) supports speech recognition and dictation. There are three ways for clinicians to use voice to generate material for inclusion in the medical record:

  1. In-System Dictation - happens when a hardware or software microphone is coupled with the CIS so that dictated text and commands interact directly with the CIS. Any amount of text, from a few words to entire letters, can be entered into the exact spot in the electronic record where it belongs. Moreover, the text can be corrected while dictating and the need for transcription is avoided. Voice can also be used to issue commands that help navigate the CIS, initiate actions (e.g. orders, billing, notes) or trigger time-saving text automations.
  2. Partial (Hybrid) Dictation - happens with a separate system is used for dictation and transcription and a token (placeholder code placed in the CIS chart) is used to automatically insert the completed transcription into the desired place in the chart. The AHS Provincial eScription system is interfaced with the Connect Care CIS for this purpose.
  3. External Dictation - happens when provindical eScription, or a completely separate system such as an independent transcription service, is used to transcribe recorded dictation and then the result is incorporated into the record through some kind of copy-and-paste or link to Netcare.

While Connect Care will support use of eScription system for partial (hybrid) dictation (#2) for a period of time, the goal is to help all clinicians shift to in-system dictation (#1) as soon as possible. External dictation (#3) is to be avoided.

Subsequent sections explain how to use the preferred in-system dictation with "Dragon Medical One". The workflow for partial dictation is very important to understand, as it involves a new use for Connect Care medical record numbers (MRN) and contact serial numbers (CSN).