Nursing dictation software for narrative notes, SBAR handoffs and care plans

Most of your shift is charted by clicking flowsheet rows, and dictation will not beat a click. Where it helps is the free text: the narrative note when something changed, the handoff summary, the care plan update, the teaching you need to document and the discharge instructions. Those are sentences, and sentences are faster to say than to type at the end of a 12 hour shift. The Healthcare dictionary in VoicePrivate has 1,661 nursing terms, with the full medical dictionary alongside.

Photo by Joaquin Reyes Ramos on Pexels

What nurses dictate

Narrative and event notes

A change in condition, a fall, a rapid response, a refusal or a call to the provider, written in order with times.

SBAR handoffs and calls

Situation, background, assessment and recommendation, ready to read from during report or before you page the provider.

Care plans

Nursing diagnoses, goals, interventions and how the patient is responding.

Wound and skin notes

Braden scale score, pressure injury stage and location, wound size and drainage, foam dressing and the turning schedule.

Patient education and discharge

What you taught, the teach back, and the discharge instructions you gave.

Care plans follow the nursing process that the American Nurses Association describes: assessment, diagnosis, outcomes and planning, implementation and evaluation. SBAR comes from the AHRQ TeamSTEPPS program, where it stands for Situation, Background, Assessment, and Recommendation (or Request).

Nursing words general dictation gets wrong

The Healthcare dictionary stores the mishearings it corrects. A few from the nursing list:

• "flebitis" to phlebitis
• "tachicardea" to tachycardia
• "telemitry" to telemetry
• "normal saleen" to normal saline
• "level of conciousness" to level of consciousness
• "fluid resusitation" to fluid resuscitation
• "surgical safety cheklist" to surgical safety checklist

What choosing Nursing does

On Mac, open Settings and set the Medical specialty to Nursing. Recognition is then primed with its core terms: Braden scale, pressure injury, sacrum, foam dressing, peripheral IV, infiltration, phlebitis, intake and output, Foley catheter, fall precautions, bed alarm, sliding scale, incentive spirometry, enoxaparin, heparin, medication reconciliation, SBAR, handoff, telemetry, ambulated, turned and repositioned, wound care, vital signs, oriented times three, pain scale and patient education. A long misheard word that is a near miss of one of those terms is matched to it first. On Windows there is no picker and the full medical dictionary is used for every note.

Example: an SBAR note after a call to the provider

Click into the note, press the hotkey, speak, and press the hotkey again. The hotkey is Ctrl+Shift+Space on a Windows workstation and Command+Shift+Space on a Mac. The text is pasted when you stop.

1. Situation. Press the hotkey and say: "Called the covering hospitalist about the patient in bed 12, 78 years old, post op day 2 after hip fracture repair. New heart rate of 118 on telemetry, sinus tachycardia." Press the hotkey again.
2. Background: press the hotkey and say: "On enoxaparin 40 milligrams daily. Vital signs at 2200 were within normal limits. Intake and output for the shift 900 in and 350 out through the Foley catheter." Press the hotkey again.
3. Assessment: press the hotkey and say: "Alert and oriented times three. Blood pressure 102 over 60, oxygen saturation 95 percent on room air, lungs clear. Peripheral IV site without infiltration or phlebitis. Possible low volume." Press the hotkey again.
4. Recommendation: press the hotkey and say: "Requested a fluid bolus and a basic metabolic panel. Orders received and read back. Will recheck vital signs in 1 hour." Press the hotkey again.

Before you count on it at work

VoicePrivate is an app you install on a Mac or Windows PC. Many hospitals do not let staff install software on shared workstations, so ask your IT department before you buy. If the EHR runs in Citrix or another remote desktop, the session must allow clipboard redirection from your computer. You also need a microphone; a headset picks up less unit noise than a laptop microphone.

Inside the EHR, VoicePrivate pastes through the clipboard and then puts back what you had copied. It works in any text field that accepts a paste, such as the narrative note field in Epic or Oracle Health (Cerner). Many nursing notes repeat the same sentences, such as a fall precautions bundle or a standard teaching statement. Text shortcuts expand a short phrase into that full paragraph, which you then edit for your patient.

Nurse practitioners

If you are an NP, your visit notes look like a physician's. See dictation for doctors and choose the specialty you practice in, such as Psychiatry / Behavioral Health for a psychiatric NP, or Nursing when nursing terms matter most.

On-device facts

Speech is processed on the Mac or Windows PC that runs VoicePrivate. Audio never leaves that computer, and nothing is sent to a cloud service for transcription. There is no recording of the patient conversation: you dictate the note yourself after or between patients. With Auto-save transcriptions on, which is the default, each dictation is also kept in the app's Library on that computer. Turn it off in Settings if you want the record system to hold the only copy.

Price

Healthcare Edition is $297 a year or $34.99 a month per clinician. There is no free trial. Individual monthly and annual plans have a 30-day money-back guarantee on the first payment. Units and practices of 2 to 20 clinicians can buy team seats.

Nursing dictation FAQ

Nurses in the emergency department can also read emergency medicine dictation, and psychiatric nurses psychiatry dictation. The EHR dictation guide covers Epic, Oracle Health and remote desktop setups.