The short answer
For every medicine in the draft, check the name, dose, unit, route and frequency against the encounter and transcript. Also check what actually happened: was it taken, given, prescribed, considered or declined? Review allergies separately, because an allergy history that was never taken is not the same as “no known allergies”.
Identify the medicine’s status
A regular medicine is not the same as a dose taken at home, a GP prescription, a medicine given in ED or one planned for later. Where it matters, name the person who gave or prescribed it and when. For example, “consider analgesia” should never become “analgesia administered”.
Keep a patient’s reported use separate from a verified medication chart. If a brand or generic name is unclear, ask the clinician to confirm it rather than choosing a likely product.
Check each dose and instruction
Read the full instruction, not just the medicine name. Compare the number and unit, the route, how often it should be used and any stated duration. A dropped digit, a decimal read as a whole number, or micrograms changed to milligrams can alter the instruction.
A note must not silently fill a missing dose from general medical knowledge. “Dose not stated” accurately reflects an incomplete source until the clinician adds the actual detail.
Keep allergy evidence separate
Confirm the substance and reaction if documented. “Allergies not discussed”, “patient reports none” and “known allergy” are not interchangeable. Do not let the template invent a negative allergy finding because the heading exists.
Before copying the note, compare the medicine list and allergy status with the authorised clinical record. Any discrepancy needs clinician resolution, not automatic model inference.
Common questions
Will DictaMed check a prescribed dose for me?
No. The practitioner must verify dose and instructions against the encounter and authorised source.
What if no allergy information was dictated?
Do not write “no known drug allergies” unless that fact was actually established.
Sources and product details
These guides describe DictaMed’s current workflow and general documentation principles. Follow your workplace policy and use clinical judgement for each patient.