Nov 22 2011

How to Dictate a History and Physical

Dictating is part of every doctor’s responsibilities, but is not formally taught in medical school. Medical students are not usually allowed to dictate when they are on clinical rotations in the 3rd and 4th years of medical school. All residents are responsible for dictating, and most learn how to do so on the job during their intern year. I have had some personal experience dictating during my clinical rotations, and I wanted to post some guidance on how to do so. The best way to learn how to dictate is through trial and error, but having a template and some advice doesn’t hurt. Below is a skeleton of a history and physical, including some ways to format your thought process.

History and Physical

Identifying Information:
“This is (your name, title) dictating a history and physical on (patient’s last name, patient’s first name), date of birth (XX/XX/XXXX) and medical record number (X).

Date of Admission:

Chief Complaint:
It is best to put the chief complaint in the patient’s own words. Just say “quote,” then what the patient said.

History of Present Illness:
“The patient is a (patient’s age) year old, (patient’s race) (patient’s gender), patient of (patient’s primary care physician), with a past medical history of (name 2-3 items of the patient’s past medical history that are most pertinent to the chief complaint), who presented to (ER, hospital, office, etc.) with a chief complaint of (from above).”

Then describe the rest of the story in chronological order as the patient described. Next, mention what happened to the patient in the ER and the reason for admission to the hospital.

Past Medical History:
(Numbered list)

Past Surgical History:
(Numbered list)

Home Medications:
(Numbered list)

(Numbered list)

Family History:

Social History:

Review of Systems:
Say the category first, then “The patient denies (symptom)” or “The patient admits (symptom).”

Physical Exam:
Say the system first, then the exam findings.

Laboratory Data:
Say “CBC shows WBCs (X), hemoglobin (X), etc.”

Say the name of the imaging modality first (chest x-ray, EKG, etc.), then the findings.

(Numbered list)

(Numbered list or explanation)

At the end of the dictation say, “Please send a copy to (patient’s primary care physician).”

To help out the transcribers, you can say the punctuation in the sentences, such as “period,” “comma,” “colon,” etc. Additionally, you can say “next paragraph” when you are going to the next section.

I hope that this template is useful and will help clear up some misconceptions or apprehension during the first few times using the dictation system. Dictating can often feel monotonous or feel like a chore, but it is very important for efficient and thorough patient care. The best way to feel more comfortable and to get better at dictating is to just do it!

Bickley, Lynn S., Peter G. Szilagyi, and Barbara Bates. “Overview: Physical Examination and History Taking.” Bates’ Guide to Physical Examination and History Taking. 10th ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2009. 6-12. Print.

1 comment

  1. Belinda Ellis

    This is one of the best examples yet. Thanks for sharing.

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