Clinical documentation guide

Doctor dictation or conversation capture: which should you use?

Choose the right source mode and handle patient conversation notice and consent according to your setting.

By DictaMedPublished 4 min read

The short answer

Use Doctor dictation when you are the only person speaking. Use Conversation when you intend to capture an exchange with the patient, after following your workplace’s notice and consent process. Both modes produce source text that the clinician must review before using the note.

Doctor dictation keeps one clinical narrator

Doctor dictation works well when you want to describe the encounter in your own words after seeing the patient or during a pause in care. You can state the history, examination and plan in sequence, and identify whether a detail came from the patient or from your own assessment.

Say when another person supplied information: “Mother reports fever for two days” and “On my examination, afebrile” communicate different facts. A clear attribution helps the eventual note avoid mixing history and examination.

Conversation capture includes another voice

Conversation mode is intended for doctor–patient speech. Before using it, follow local rules for advising the patient and obtaining any required consent. The in-app consent control is optional in doctor-only dictation, but it does not replace the organisation’s own process for a patient conversation.

A clinical conversation includes questions, tentative ideas and corrections as well as established findings. When reviewing the transcript, separate what the patient reported from what you confirmed. A question asked aloud should not turn into a diagnosis in the note.

Use the same review process for both modes

Check the complete transcript and any context, then review the clinical note before copying it to the authorised record. If speaker identity or meaning is unclear, clarify it instead of relying on the model to infer who said what.

Common questions

Does selecting Conversation establish consent?

No. Follow the applicable patient notice and consent process for your workplace and setting.

Can I use Doctor dictation after a visit?

Yes. Make clear what the patient reported, what other clinicians found and what you observed.

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.

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