Health Information Management
Transcription Services
Edmonton Zone
Priority dictations, obtaining a dictation User ID #, or any other inquiries during regular business hours:
Grey Nuns: 780-490-5903 (0700 to 1500 hours)
Misericordia: 780-735-2619 (0800 to 1600 hours)
TIPS TO ENSURE ACCURATE SERVICE, ALWAYS:
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Prepare/organize data before beginning dictation.
State and spell your first and last name.
State the name of the attending physician.
State and spell the patient’s first and last names.
State the patients date of birth (i.e. 4 June 1963)
State the patient’s complete Medical Record Number
(MRN).
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State and spell the first and last name for copy recipients (i.e.,
family/referring physician’s etc.).
** The copy will not be sent if there is uncertainty regarding
the intended recipient.
State ALL dates pertinent to the dictation (operative date,
admit & discharge dates, etc).
RESIDENTS/CLINICAL CLERKS/FELLOWS/CLINICAL ASSOCIATES/STUDENT INTERNS: Always state the attending
physician’s first and last name at the beginning of each dictated report.
TO ACCESS THE EDMONTON DICTATION SYSTEM DIAL:
780-407-2800 or 780-407-2850
 Enter your personal dictation
identification number – followed by #.
 If prompted for a zone identifier,
enter 1 for Capital Health.
 Enter the numeric patient
location identifier followed by #
 Enter the numeric work type
identifier followed by #
 Enter the Patient ID number (MRN)
followed by #
Numeric
ID
1
2
3
4
5
6
7
8
9
Work type
number
1
2
3
4
5
Patient Location
description
Glenrose
Grey Nuns
Leduc
Misericordia
Royal Alexandra
Sturgeon
University of Alberta
Fort Saskatchewan
DKML
Description
Histories (inpatient)
Consultations (inpatient)
Discharge Summaries
Operative Reports
Procedure Reports
Numeric
ID
10
11
12
14
15
16
17
18
19
Patient Location
description
Devon
Redwater
Westview
Morinville
Health First Strathcona
Stollery
Alberta Hospital Edmonton
Northeast CHC
Villa Caritas
Work type
number
6
8
10
12
33
Description
Obstetrical Discharge Summary
EEG/EP Reports
Outpatient Clinic Reports
Letters (outpatients)
Transfer Summary
 Enter the Case Number followed by #
 Intermittent tone –
PRESS 2 to begin dictating.
Updated: August 2014
KEYPAD
NUMBER
2
3
4
44
5
7
77
8
FUNCTION
Start and stop dictation
For incremental rewind with automatic playback
For fast forward
To forward to the last word dictated
To complete and disconnect
To rewind
To rewind to the first word dictated
To complete current report and start a new report
Health Information Management
Transcription Services
IMPORTANT INFORMATION
Please always remember to use a corded land line and speak clearly, slowly
and directly into the phone - as if you were speaking to a patient.

Ensure you always use the correct work type. The work type that you key into the dictation system =
the template format and distribution that the transcription system will use for your documentation.
Using the wrong work type may result in your report being routed for transcription incorrectly.

There are many doctors with similar names so please ensure that you clearly state and spell the first
name, last name and state the specialty for care providers that you need copies to be sent to (i.e.,
family, attending, etc).
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Ensure that you always identify yourself and state the first and last name of the attending physician
that you are working with at the beginning of each dictated report.
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If you were cut off and have an incomplete report, dictate the second portion making reference to
the Job ID and MRN of the original report and state that you are dictating an addendum or a
continuation of the previous report.
o Please note that you may not add an addendum to a report that you did not originally
dictate.
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Do not enter any incorrect patient information; this results in delay of the report being transcribed
and physician deficiencies will not be updated.
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Do not use another dictator's dictation number. If you do not have a dictation number, please call
Transcription Services at your site (see page 6) to obtain one.
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Do not dictate more than one patient or more than one report per dictation. Any dictations
containing more than one report will only have the first dictation transcribed; the remaining
dictations will need to be re-dictated.
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Please DO NOT access the dictation system while:
o in a noisy environment (i.e. background noise, side conversations, operating room scrub
station, etc.).
o using a cordless or cellular phone or other wireless devices - signal/reception fluctuates and
results in inaudible dictation.
o using a phone line with static - If you can hear static on the line please do not continue to
dictate. The static records louder than your voice, making your dictation inaudible.
o eating, chewing gum, eating candy, etc.
Updated: August 2014
Health Information Management
Transcription Services
WORK TYPES BY HOSPITAL LOCATION
COVENANT HEALTH SITES:
Grey Nuns Community Hospital (patient location – 2):
1
Histories (inpatient only)
2
Consultations (inpatient only)
3
Discharge Summaries (for inpatient admissions only)
4
Operative Reports
5
Procedure Reports
6
Obstetrical Discharge Summaries
8
EEG Reports/Evoked Potential Reports
10
Outpatient Consultation
12
Outpatient Letters (to referring physicians only)
33
Transfer Summary (Nurse Practitioner use only)
Misericordia Community Hospital (patient location – 4):
1
Histories (inpatient only)
2
Consultations (inpatient only)
3
Discharge Summaries (for inpatient admissions only)
4
Operative Reports
5
Procedure Reports
6
Obstetrical Discharge Summaries
8
EEG Reports/Evoked Potential Reports
10
Outpatient Consultation
12
Outpatient Letters (for iRSM and Dr. Boychuk only)
33
Transfer Summary (Nurse Practitioner use only)
Villa Caritas (patient location 19):
1
Histories
2
Consultations
3
Discharge Summaries
Updated: August 2014
Health Information Management
Transcription Services
Discharge Summary Format
A discharge summary should be a brief synopsis of the significant events occurring during a patient’s hospitalization.
Please include paragraph headings in your dictation.
AUTHOR:
Identify yourself and your title. House staff and student interns
new to the hospital should spell their surnames.
PHYSICIAN RESPONSIBLE:
If different from the personal doing the dictation.
PATIENT NAME:
State surname first and spell, follow with the given name and spell.
PATIENT IDENTIFICATION NUMBER: This is the patient’s Medical Record Number (MRN). This number
appears on the Patient Registration Form.
COPIES TO BE SENT:
Indicate copies for WCB, Cross Cancer Institute and other
physicians. Spell the physician’s SURNAME, give the FIRST name
and address as complete as possible.
ADMISSION DATE:
This date appears on the Registration Form.
DISCHARGE DATE:
This date appears on the Registration Form.
DATE OF BIRTH:
DOB is for patient ID verification and is on the Registration Form
CLINICAL HISTORY:
Include reason for admission and relevant history of past health.
PHYSICAL EXAMINATION:
Include mental status examination if appropriate.
INVESTIGATIONS:
Include all SIGNIFICANT lab, radiology findings normal or
abnormal.
TREATMENT AND PROGRESS:
Include significant events of patient’s hospitalization and condition
on discharge. INCLUDE OPERATIONS STATING EACH PROCEDURE
PERFORMED, DATE OF PROCEDURE AND SURGEON’S NAME.
DISCHARGE MANAGEMENT PLAN:
Include where the patient was discharged (i.e. home, nursing
home, etc.), follow-up physician and follow-up investigations.
List the medications and dosages the patient was discharged on.
Please spell out any uncommon medications.
CONSULTANTS:
List each consultant, giving surname and initial.
DISCHARGE DIAGNOSES: USE THE FOLLOWING FORMAT WITHOUT ABBREVIATIONS OR SYMBOLS.
MOST RESPONSIBLE DIAGNOSIS: The one most significant condition responsible for the stay in the
hospital.
PRIMARY DIAGNOSES: Other important conditions that significantly impact the patient’s
management or length of stay, i.e. CONTRIBUTES TO THE COST OF
THE HOSPITALIZATION.
SECONDARY DIAGNOSES: An incidental condition which did not contribute to the length of
stay and for which the patient may or may not have received
treatment.
COMPLICATIONS: A condition arising after a patient’s hospitalization which has a
significant influence on the patient’s management or length of
stay. NOTE: This may also be the Most Responsible Diagnosis.
Updated: August 2014
Health Information Management
Transcription Services
Obstetrical Discharge Summary Format
An obstetrical discharge summary should be a brief synopsis of the significant events occurring during a patient’s
hospitalization. Please include paragraph headings in your dictation.
AUTHOR:
Identify yourself and your title. House staff and student interns
new to the hospital should spell their surnames.
PHYSICIAN RESPONSIBLE:
If different from the person doing the dictation.
PATIENT NAME:
State surname first and spell, follow with the given name and spell.
PATIENT IDENTIFICATION NUMBER This is the patient’s Medical Record Number (MRN). This number
appears on the Patient Registration Form.
COPIES TO BE SENT:
Indicate copies for WCB, Cross Cancer Institute and other physicians.
Spell the physician’s SURNAME, give the FIRST name and address as
complete as possible.
ADMISSION DATE:
This date appears on the Patient Registration Form
DISCHARGE DATE:
This date appears on the Patient Registration Form.
CLINICAL HISTORY:
Include reason for admission and relevant history.
PHYSICAL EXAMINATION:
INTRAPARTUM EVENTS:
Include significant labor events. INCLUDE CESAREAN SECTION
OR OTHER OPERATIONS STATING EACH PROCEDURE PERFORMED,
DATE OF PROCEDURE AND SURGEON’S NAME.
NEWBORN OUTCOME:
Specify normal or if abnormal indicate nature of problem and follow-up
DISCHARGE PLAN:
Include mention of where the patient was discharged (i.e. home,
other facility, etc.), medications, follow-up physician and follow-up
investigations.
DISCHARGE DIAGNOSES: USE THE FOLLOWING FORMAT WITHOUT ABBREVIATIONS OR SYMBOLS.
MOST RESPONSIBLE
The one most significant condition responsible for the greatest
DIAGNOSIS:
length of stay.
PRIMARY DIAGNOSES:
Other important conditions which significantly impact the patient’s
management or length of stay, i.e. CONTRIBUTES TO THE COST OF
HOSPITALIZATION.
SECONDARY DIAGNOSES:
An incidental condition which did not contribute to length of stay
and for which the patient may or may not have received treatment.
COMPLICATIONS:
A condition arising after a patient’s hospitalization which has a
significant influence on the patient’s management or length of stay.
NOTE: This may also be the Most Responsible Diagnoses.
Updated: August 2014
Health Information Management
Transcription Services
MEDICAL TRANSCRIPTION SERVICES
Edmonton Dictation numbers: 780-407-2800 or 780-407-2850
(i.e. a physician calls and asks for the number they use to Dictate into)
BUSINESS OFFICE HOURS OF OPERATION:
COVENANT HEALTH GREY NUNS TRANSCRIPTION SERVICES: Monday to Friday 0700-1500
Phone: 780-490-5903
COVENANT HEALTH MISERICORDIA TRANSCRIPTION SERVICES: Monday to Friday 0800-1600
Phone: 780-735-2619
AFTER HOURS (evenings, weekends and statutory holidays):
Questions, inquiries, obtaining Author/Dictator Identification Number
for Physicians, Residents and Students:
GREY NUNS TRANSCRIPTION SERVICES: Leave a message at 780-490-5903
MISERICORDIA TRANSCRIPTION SERVICES: 780-735-2799
For technical assistance (i.e. cannot access dictation system),
call the Information Center Help Desk: 780-735-4357
Updated: August 2014