Lax record keeping CMAJ 1997;156:631 To the tips for keeping good medical records given in the article "Physicians who keep lax records put careers in danger, college course warns" (CMAJ 1996;155:1469-72 [in brief / en bref]), by Dee Kramer, I would like to add consideration of transcribed records. After my internship in 1981, I would have been one of those with very poor writing and difficulties in time management, and I would have easily succumbed to poor record keeping. However, I had joined a clinic in which the records were dictated and transcribed. There is an obvious overhead cost associated with dictation; however, in terms of the clarity of the records, the ability to be succinct and the ability to dictate a referral note or significant other record immediately (avoiding the necessity of pulling charts later or having charts pile up on your desk) there is a distinct advantage. The ongoing typed record also provides a good organization tool that allows the temporal sequence of care to be easily documented. Effective dictating may also reduce the time-frame for making records from the suggested 5 minutes to only 1 or 2 minutes; furthermore, records can be made immediately after the patient is seen, while the visit is still fresh in the physician's mind. Cost aside, with the time saving and the ability to organize the files easily and to provide documentation of the good work and the amount of work done, there are potential benefits to transcribing records. In the future, as computer voice-recognition systems become more effective, they may also allow for cost-effective transcription. Patrick J. Potter, MD Chief Physical Medicine and Rehabilitation University of Western Ontario London, Ont. Send a letter to the editor responding to this letter Envoyez une lettre à la rédaction au sujet de cette lettre | CMAJ March 1, 1997 (vol 156, no 5) / JAMC le 1er mars 1997 (vol 156, no 5) | / >