Dragon Copilot experience for nurses verbalization guide

Purpose of this guide

This guide helps you master verbal documentation using Dragon Copilot’s ambient technology. It provides general tips and best practices followed by tips specific to LDAs to ensure that your documentation is captured accurately and in real time.

Verbalization and patient safety

Verbalization supports accurate documentation and patient safety. It helps capture information that might otherwise go undocumented and helps patients understand their care.

General verbalization best practices and user tips

  • Be specific: Don't expect the product to calculate, infer, or supply missing information. Avoid generic terms such as "good," "fine," or "normal." Verbalize the measurements, scales, locations, laterality, routes, subscores, and other details you want documented.
  • Specify location and laterality: Include the location of findings when applicable. For example, say "right radial 2+" instead of "positive pulses."
  • Orientation/Alert and oriented: Verbalize person, place, time, and situation, or use "Neuro WDL" when appropriate. Ask orientation questions aloud (for example, name, year, and location) and verbally reorient the patient when needed.
  • Verbalize outside the room when appropriate: Record a brief monologue outside the patient room to capture observations, assessments, or additional details that require privacy or aren't appropriate to discuss in front of the patient.
  • Wait and restate: When corrections are needed, wait a few seconds and start a new sentence with the details you want captured.
  • Recording environment: Minimize background noise. Mute the TV and use the pause function during sidebar conversations or discussions that shouldn't be captured in the recording.
  • Time changes: The documented time reflects the recording time unless changed manually before filing. LDA addition and removal times are an exception and should be verbalized.

LDA verbalization best practices

  • Include key LDA details: State the LDA type, location, status, and any relevant measurements or output.
  • Document placement clearly: Use terms such as inserted, placed, or applied when documenting a new LDA. Use in place only when documenting an existing LDA.
  • Discuss one LDA at a time: Describe each line, drain, airway, wound, or device separately to improve documentation accuracy.
  • Use a brief monologue when needed: Use a short, clear monologue to capture LDA details that aren't naturally discussed during the patient interaction.

Verbalization examples

The following sections provide effective verbalization examples, sorted by topic.

Vital signs

  • "Your blood pressure is 118 over 72 and your heart rate is 76. Both are right where we want them. Your oxygen level is 97 percent on room air."

  • "Temperature 100.5 orally. Heart rate 98. Respirations 18. Blood pressure 100 over 50 in the left arm. Oxygen saturation 98 percent on two liters oxygen via nasal cannula."

Pain and safety

Pain

  • "On a scale of zero to ten, how would you rate your pain right now? A four, in your lower back, and it’s more of an aching feeling. Thank you. I’ll bring your scheduled pain medication and we’ll recheck in about an hour."

  • "Complains of lower back pain radiating to the left leg. On a zero-to-ten pain scale, rates pain as six. Describes pain as sharp, shooting pain. Patient-stated pain goal is three. Medication administered."

Safety

  • "Your call light is right here within reach. Push that red button if you need anything at all. Both side rails are up for your safety, and your bed is in the low, locked position."

  • "That beeping you just heard: I’ve turned on a chair alarm to remind you to call me before getting up on your own."

  • "Repositioned in bed to the left lying side with two staff assist. Heel protectors on. Bed in low position. Bed alarm on. Side rails up times two. Call bell in reach."

Head-to-toe assessment

Neurological

  • "Can you remind me of your full name? And what year are we in? What type of place are we in today?"

  • "Oriented to person and situation.”

HEENT

  • "Your pupils are equal and reacting to light just like they should. I don’t see any swelling or drainage, and you’re swallowing without any difficulty.”

Respiratory

  • "Your lungs are clear on both sides. That’s exactly what we want to hear. Your breathing is even and unlabored, and you’re not using any extra effort to breathe.”

  • "I hear some crackles at the base of your right lung, which fits with the pneumonia we’re treating. The antibiotics and the breathing exercises we’re doing will help clear that."

Cardiac

  • "Your heart rhythm is regular, and your heart rate is 76, right in the normal range."

Peripheral vascular

  • "I can feel strong pulses in both of your feet: 2+ on the right and 2+ on the left. Your feet are warm with good color."

  • "As I look at your feet and lower legs, I see moderate swelling. When I push my finger down on each leg, it leaves a mark. The medications in your treatment plan will help bring this down, and we’ll keep an eye on it."

Integumentary

  • "Your skin is warm, it’s dry, and I don’t see any redness or breakdown. Everything looks just like we’d expect."

  • "Incontinent of urine. Peri care provided; perineum cleansed. Gown, bed pad, and linens changed. Coccyx reddened. Skin moisture barrier cream applied."

Gastrointestinal

  • "I’m listening to your abdomen and I hear active bowel sounds throughout. Your belly is soft, and you’re telling me there’s no pain when I press. When was your last bowel movement?"

Genitourinary

  • "You urinated about 350 milliliters. It’s clear and yellow. That’s great news. It means your kidneys are working well, and it checks off one of the steps toward going home."

  • "Urine output 350 mL from Foley. The urine color is yellow and cloudy."

  • "Intake of 350 mL. Seventy-five percent of meal consumed. Drank fifty percent of Ensure. Three hundred mL urine output, clear and yellow in color. Patient had one unmeasured bowel movement."

Musculoskeletal and mobility

  • "Push down on my hands like you’re pressing a gas pedal. Excellent. Your left foot is nice and strong, and your right foot has moderate weakness, which is consistent with what you told me about your hip replacement."

  • "Out of bed to chair with one assist, able to stand and pivot, tolerated well."

  • "Ambulated to the bathroom independently, gait steady."

Psychosocial

  • "You mentioned you’re feeling anxious about your surgery tomorrow. That’s completely understandable. It’s great that your daughter will be here with you. Would you like me to have the chaplain or a counselor stop by today?"
LDAs

  • "I’m checking the IV in your left forearm. The site is clean, dry, and intact, and so is the clear dressing over it. I’m going to flush it now; you might notice a cool feeling or a slight taste."

  • "Left forearm PIV. Site clean, dry, intact. Transparent dressing clean, dry, intact. Line flushed and saline locked."

  • "Left upper arm PICC. Site clean, dry, intact. Blood return noted. Line flushed. Cap changed."

  • "Foley catheter. Urine output 350 milliliters. Urine yellow and cloudy."

  • "JP drain at the abdominal surgical site emptied. Sixty milliliters serosanguinous drainage. Site warm and red."

  • "Abdominal incision. Site clean and dry. Edges approximated. ABD dressing clean, dry, intact. Scant serosanguinous drainage."

  • "Left forearm PIV. Site infiltrated. Leaking noted. Unable to flush. Removed."

  • "Left forearm 20-gauge PIV removed due to infiltration."

  • "New peripheral IV, 22-gauge, placed in right forearm."

Daily cares and positioning

Daily cares

  • "Teeth brushed, peri care performed, patient bathed with prepackaged wipes, gown and linens changed. Patient completed all hygiene tasks independently."

Comfort and positioning

  • "I’m going to help you roll onto your right side and tuck these pillows behind your back and between your knees. I’m raising the head of the bed. How does that feel?”

  • "Head of bed elevated.”

  • "Pillows and positional supports in use."

  • "Patient lying in bed, needing maximum assistance to turn and position."

Verbalization videos

The following optional videos provide additional verbalization examples:

Dragon Copilot experience for nurses quick start guide

Dragon Copilot experience for nurses best practices and tips

Start your first recording (nursing)