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.