The short answer
A DictaMed draft can begin with dictation or pasted information and include a relevant image or PDF. Before generating the note, check any extracted text against the original, make clear which details came from an earlier record and which came from your examination, and review the combined material.
Choose only relevant source material
DictaMed accepts voice, pasted text, images and PDFs in the note workflow. Useful additions can include a medication history, a result already available or a short pre-charting summary. Use the minimum information needed for the encounter and follow your workplace rules on sharing records.
Before uploading a photograph or PDF, check whether it includes names, dates, identifiers or pages unrelated to this encounter. Text extracted from a document is source material. It does not become a confirmed finding from today merely because it appears in the draft.
Check text extracted from documents
Optical extraction may misread handwriting, decimals, units, laterality or a scanned table. Compare the extracted text with the original image or PDF before it informs the clinical note. If the source says “pending”, preserve that status. If a value is unreadable, do not supply a guessed value.
Distinguish earlier documents from today’s review. “Previous discharge summary states…” is different from “Today’s examination shows…”. This distinction prevents old findings from appearing as fresh observations.
Build one reviewable clinical story
Once the sources are together, read through them as one account of the encounter. If two sources disagree, resolve the difference before generating the note or leave it clearly marked for review. The final story should still show what happened before arrival, what you observed today and what is planned next.
Common questions
Can I paste a prior hospital note?
Use relevant material only when permitted by local policy, and identify it as prior documentation.
Is extracted PDF text automatically correct?
No. Check it against the original document, especially clinical numbers and medicine details.
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.