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Resident Orientation Manual

Produced by Galveston Shriners Burn Hospital and
The University of Texas Medical Branch Blocker Burn Unit.
Contributors:  Sally Abston MD, Patricia Blakeney PhD, Manubhai Desai MD,
Patricia Edgar RN, CIC,John P Heggers PhD, David N Herndon MD,
Marsha Hildreth RD, Ray J Nichols Jr. MD
 

DICTATION SYSTEM
Shriners Hospital For Children
815 Market St.
Galveston, TX  77550-2725

To Dictate:  (follow the voice prompts)

1.  Enter your 6-digit ID (your dictating #).
2.  Enter the 2-digit Work Type (see list).
3.  Enter the visit # (FIN) do not enter 0's.
4.  Begin dictating after the beep (very faint, please listen).

DEPARTMENTS
 

10 - General Surgery

14 - Plastics

11 - Ortho 15 - Otolaryngology
12 - OutPatient/Nursing Svc 16 - Maxillofacial
13 - Rehab 17 - Other

WORK TYPES
 
70 - History & Physical 74 - Inpatient Progress Notes
71 - Operative Reports 76 - Outpatient Progress Notes
72 - Discharge Summary 77 - Radiology
73 - Consults 78 - Perioperative Note
81 - Path Note  

   To dictate another report, press "5" and repeat from step 3.  Please press "9" to disconnect at the end of your dictation session.

   If you wish to change from Dictate to Report Review, after you have pressed "5" to end your current dictation, press "#" then "1".  Listen to the voice prompts for Review choices.

   To change from Report Review to Dictate, press "#" then "2".

   To Insert Text:

1.  Press "4" to pause at the point where you wish to insert text.
2.  Press "#" then "6" to switch to the insertion mode.  Dictate the new text.
3.  Press "3" to rewind and verify the change.

Lanier Keypad Functions
 

1
Listen
 

2
Record
 
3
Short Rewind
4
Pause
5
Next Report
6
Insert
7
Fast
Forward to End
8
Rewind to
Beginning
9
Manual Disconnect
*
Clear ID
0
Not Used
#
Shifted Functions
 

FORMAT FOR DICTATION

Discharge Summary:
   When dictating the discharge summary, please indicate your name and title, the staff physician's name, the date of admission, date of discharge and the patient unit history number.

*  Chief Complaint
*  History of Present Illness
*  Physical Examination
*  Diagnostic Laboratory and X-Ray Findings
*  Hospital Course
*  Operations (include date, pin insertions, and donor site)
*  Final Diagnosis
*  Condition on Discharge (this should be compared to the admission status)
*  Disposition (include special instructions for wound care)
    a) Medications                 c) Physical Activity
    b) Diet                             d) Follow-up and Plan

Operative Reports:
   When dictating operative reports, please indicate your name and title, the staff physician's name and any assistants present during the operation, the date the procedure was performed and the patient unit history number.

*  Pre-Operative Diagnosis
*  Operation (name of procedure performed)
*  Post-Operative Diagnosis
*  Indications
*  Operative Findings
*  Procedure (detailed explanation)
*  Estimated Blood Loss
*  Sponge and Needle Count
*  Condition of Patient on Transfer
*  Cm2 skin excised

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