Advice for medical scribes?

[LSphantom]

I have been a part-time medical scribe in the ED for less than a year, and feel that I have greatly improved since training. However, I still feel as if I walk into some of my shifts insecure about my charting abilities. Most of the physicians are too nice to give criticism (I ask for advice and they just say something along the line of ("you're fine"), however, I definitely don't feel like I am the best scribe out there.

For all the physicians out there: What are some things that really make a great scribe stand out? Do you have any tips for writing a better MDM/ED course? Speak your mind and don't hold back!

For all the experienced scribes out there: What are some things that have helped you the most? Are there any specific dotphrases that you use often? Do you have any time-saving tricks up your sleeves?

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[Groove]

This is a broad question and you are apt to get greatly varied responses depending on the specific attending you're working with as we all chart differently. High value dot phrases in one of my charts might not be valued at all in the next doctor's chart and vice versa. Your best and easiest bet is to just learn each physician's preferences (ask them point blank) and form your macro/dot phrases and methodology accordingly.

I also think it helps to have conceptual awareness of "defensive charting" from a medicolegal standpoint and understand the importance of things like re-evaluations, discharge instructions, memorializing accurate consultant discussions/recs, transition of care documentation, ROS pertinent negatives, etc..

If you're pre-med, don't make the job overly complicated by trying to piece together an algorithmic approach that suits all physician's needs because you aren't going to have much success. Instead, learn each docs preferences, customize your macros and focus on speed, efficiency and accuracy. You're likely to become one of their favorite scribes to work with and you can obtain some good experience and an easy strong letter of recommendation for med school or whatever.

I would leave the MDM/ED Course for the doc. I never ask my scribe to write those.

Know that although we often times take you guys for granted, your contribution to our work flow is greatly appreciated. I have much less stress when I have a great scribe working with me during a busy shift.

 

[swamprat]

Don’t write down everything the patient says


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[Jabbed]

I think that it's unreasonable for scribes to come up with MDM and most of what you write will surely be deleted. Scribed for 5 years and only now realize that I had no idea what the doctor was really thinking.

You'll mostly learn by seeing how the ED doc edits your chart before locking it. Pay attention to order sets, let them know when the workup is back. Once you're familiar with the day to day you can throw in small analysis ("repeat troponin was negative, admit to chest pain center?")

As swamprat said, don't write everything that the patient says. Words/phrases like "weakness", "headache", and "cannot walk" should be used sparingly.

Keep progress notes and procedure notes up to date. If locking a chart just involves minor edits and writing an MDM, you've done your job.

Try to learn, be humble, and realize that a significant amount is just going over your head and that you won't even realize it.

 

[LSphantom]

I would leave the MDM/ED Course for the doc. I never ask my scribe to write those.

My department actually expects us to do this part (and it is the part that I feel needs the most work). Otherwise, I do feel as if my defensive charting and overall consistency have greatly improved.

Don’t write down everything the patient says

This is a great point. Especially in terms of being more efficient with time. I find myself writing a very detailed HPI compared to other scribes, which often takes time away from focusing on other things.

 

[Angry Birds]

1. Come 15 minutes early to your shift.
2. Never call your doctor by his/her first name, unless they super insist. Even then, not in front of patient or other staff.
3. In regards to not writing everything down, this is not just in terms of efficiency, but also for medico-legal reasons. If in doubt, ask the physician, "should I really include the chest pain (which was in ROS)"?