Advice for newly hired medical scribe

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Neutropix

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Disclaimer: I used SDN's search function, but I could not find any answers to my question (sorry if this has been asked before).

Anyways, I received a phone call last week informing me that I have been offered to work as a medical scribe; the company forwarded me a study packet, which I will be starting on today.

Could you all please give me tips on how to be a successful medical scribe? I know what to expect for the most part. However, I'm sure you all can bestow some secrets, which I would have to learn the hard way. Another scribe suggested I take medical terminology, for example.

Thank you kindly,

Ahab

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Most potential scribes wash out in training if they don't take it seriously. Memorize the training packet, show up to training. show some enthusiasm. This is a job that pays about the same as McDonald's, but you are doing it for the experience. You get out of it what you put into it. Just remember, it takes about 3 months to get efficient, up-to-speed on the computer program, and learning how different people do different things, even in the same ER. And if you don't type well/fast, practice. Otherwise, it is a pretty easy job, with some interesting cases to watch. Best wishes to you.
 
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Hey congrats on getting the job! Hope these points help.

- Google is your friend. Don't know a word? Sound it out and put it in google (make sure it makes sense in context lol)

- Remember that you're telling a story. It's more than just a set of symptoms; you're putting the symptoms in context to the patient and surrounding factors.

- Following the above bullet, try to be as succint and accurate as possible and don't take it personally if Docs completely amend your chart (most will make minor changes); You don't have 8+ years of med training (echoing @Hospitalized from previous post) (I'm a closet-perfectionist and I still have issues with this point sometimes lol)

- If you find yourself in the situation where your charts are being frequently amended by multiple docs, ask how to improve your HPI composition. Who better to ask than your doctor? They'll respect that you are trying to learn and improve.

-In general, don't be afraid to ask questions even if they are repetitive (especially in the beginning). It's better that you record the correct information than to put down the wrong stuff and get chewed out for it. That being said, learn from each question so that you're not asking the exact same things that you were on day one.

Eventually, you'll switch over to autopilot and have more time to learn the medicine. I absolutely love scribing in my ER and I'm glad I have the opportunity to be right in the mix of everything. Good luck moving forward!
 
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My post from this thread: http://forums.studentdoctor.net/threads/tips-on-being-a-good-er-scribe.1115183/#post-16055447

First and foremost, come to terms with yourself that you do not have 8+ years of medical training. You do not have the knowledge to understand every case to the extent a physician does, so they simply cannot expect you to be able to fill in every detail for the chart that they are implying when they evaluate the patient.

For yourself, KEEP A LIST OF PATIENTS. I can't emphasize this enough. It keeps everything straight. Some doctors request it, other don't. You should ALWAYS have one.

You should try to document everything that occurs on your shift. You want to shoot for a 100%. But, let's be real. There's absolutely no way you can get 100% of all information on every one of your shifts. Doctor's forget to put orders in, forget to consult a specialist on a patient, and even forget to ask pertinent questions at times. We are humans, we're not perfect. I put myself around 96-100% on a regular basis, and physician's I work with treat me very well and tell me my charts are good. There are times when I've forgotten very pertinent information. It happens. Like I said, we're not perfect. When I'm in doubt, I always just ask the physician, "is there anything else specific you would like in this chart before I'm done with it?" before discharge/admit. This covers both you and the physician. Often times, they say something that's probably already in there. This lets you know that you are doing your job correctly, as you've gotten the most pertinent information in the chart (the thing that first came to mind for them).

You will begin to catch on to presentations that occur over and over, and things that physician's tend to look for, like meningeal signs in a headache, peritoneal signs in abdominal pain, wheezes/rhonchi/rales in coughers/SOB, and so on. This stuff gets routine and you will have go-to phrases you can put in your MDM. I'm to the point now where I can do a level 5 chart in <5 minutes after the assessment. When I was first on my own, I wouldn't even be able to comprehend what I do with charts now and the efficiency I've learned.

At the end of the day, you are creating a chart that 95% of the time has minimal significance, ever. The most important charts are when patients get admitted, have an extensive medical/ER visit history, or are hostile towards the doctor (as that could be the one that goes to court). Doctor's will dictate to you more on these charts, naturally. Or at least I hope they do. And they probably go back and edit them after shifts more frequently.

Your trainers and program will stress the crap out of you saying how important your job is. Ultimately, you are just making the physician's life easier and doing their dirty work. Come to terms with that, master it, and then start learning medicine. It's a very fortunate position to be in.
 
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You need tips on how to be a good scribe? Smh lol you SDNers are so neurotic lol
 
You need tips on how to be a good scribe? Smh lol you SDNers are so neurotic lol

What's the problem with asking people who have experience on how to be a good employee?

Sounds like you are not resourceful.
 
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You need tips on how to be a good scribe? Smh lol you SDNers are so neurotic lol
My post from this thread: http://forums.studentdoctor.net/threads/tips-on-being-a-good-er-scribe.1115183/#post-16055447

First and foremost, come to terms with yourself that you do not have 8+ years of medical training. You do not have the knowledge to understand every case to the extent a physician does, so they simply cannot expect you to be able to fill in every detail for the chart that they are implying when they evaluate the patient.

For yourself, KEEP A LIST OF PATIENTS. I can't emphasize this enough. It keeps everything straight. Some doctors request it, other don't. You should ALWAYS have one.

You should try to document everything that occurs on your shift. You want to shoot for a 100%. But, let's be real. There's absolutely no way you can get 100% of all information on every one of your shifts. Doctor's forget to put orders in, forget to consult a specialist on a patient, and even forget to ask pertinent questions at times. We are humans, we're not perfect. I put myself around 96-100% on a regular basis, and physician's I work with treat me very well and tell me my charts are good. There are times when I've forgotten very pertinent information. It happens. Like I said, we're not perfect. When I'm in doubt, I always just ask the physician, "is there anything else specific you would like in this chart before I'm done with it?" before discharge/admit. This covers both you and the physician. Often times, they say something that's probably already in there. This lets you know that you are doing your job correctly, as you've gotten the most pertinent information in the chart (the thing that first came to mind for them).

You will begin to catch on to presentations that occur over and over, and things that physician's tend to look for, like meningeal signs in a headache, peritoneal signs in abdominal pain, wheezes/rhonchi/rales in coughers/SOB, and so on. This stuff gets routine and you will have go-to phrases you can put in your MDM. I'm to the point now where I can do a level 5 chart in <5 minutes after the assessment. When I was first on my own, I wouldn't even be able to comprehend what I do with charts now and the efficiency I've learned.

At the end of the day, you are creating a chart that 95% of the time has minimal significance, ever. The most important charts are when patients get admitted, have an extensive medical/ER visit history, or are hostile towards the doctor (as that could be the one that goes to court). Doctor's will dictate to you more on these charts, naturally. Or at least I hope they do. And they probably go back and edit them after shifts more frequently.

Your trainers and program will stress the crap out of you saying how important your job is. Ultimately, you are just making the physician's life easier and doing their dirty work. Come to terms with that, master it, and then start learning medicine. It's a very fortunate position to be in.
Thank you very much for the details; these are all things I will keep in mind. Yes, I feel very fortunate to be in this position. I live in a city where it is challenging to become a scribe (small town with a lot of competition), which is why I thought it might be not be a bad idea to get advice from SDN (you all seem to know everything).
 
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