7331poas

2+ Year Member
Jun 16, 2015
2,350
2,292
Status
Medical Student
Ok im cross posting this from reddit where I also posted this.

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I'm going to write some of the things that I do that improve my work as a scribe, and possibly help those looking to become ED scribes, those starting out, and possibly those who have already scribed for a period of time. Most importantly, if you think something I am doing is suboptimal or something to add just throw in your thoughts.

Your steps to being at least competent

STEP 1: Introduce yourself to your "providers"

At the ED I work at the basic setup is you show up to the ED, and whoever is on that night is who you are working with. This is generally residents and PAs. Sometimes attendings.

At minimum you need to have a 10 second discourse with these guys and let them know you are there and you are ready to see people. Id say when I was first starting out I would show up and expect them to let me know when they want to see people. Being proactive and "eager" to see patients breaks the ice and leads to you seeing many many more patients. I was certainly establishing better relationships with the residents/PAs just from a very very simple hello and introduction. Also developing a dry sense of humor will help.

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STEP 2: Writing the note

Ok we are done with that crap.

Writing the note. Initially my notes were delivered slowly and, more importantly, there were details missing that would be relevant to the doctor. To solve this issue I reverted back to my roots and choose to write the note "algorithmically". I now aim to write the exact same note for every patient.

Basic outline for a "normal" interview:

<Age> year old <Sex> with <PMH of / no reported PMH> presents to the ED <via transport/ by transfer> for evaluation of <chief complaint> <s/p surgery (if necessary)>. <If the patient has relevant PMH which is related to the CC insert a sentence(s) here>. The patient was in their usual state of health until <time when symptoms onset> when, while <what the patient was doing when symptoms onset (if pertinent) (stressors? no stressors?)>, he/she (first?) developed the <acute/gradual> onset of <location> <pain> with <negative/positive radiation to site>. The <pain> is <number/10> in severity, described as <type of pain (burn ache etc)>, and <constant/intermittent>. Associated with the onset of <chief complaint> was <chiefly related symptom> which first onset <when that symptom onset (reformat this if necessary)>. <Endorses exacerbating pain on condition (palpation? eating? changing position? amulation?> <Denies mitigating factors including whatever the Dr asked> Denies any <denied symptoms (usually one which is directly related to the recent sentences)>. Endorses <other reported symptoms>. He reports never experiencing pain of this character before. OR The patient has experienced pain of this character when <when did he have this pain and what was found at that time (also what therapies for symptoms at that time)> <From here you need to list other complaints and deviate from script>. <Endorses taking OTC pain meds for his current complaints with no relief (for instance)> <Include specifically if there are recent medical notes for the current patient which are related to the current complaint. Including important statements that that physician made>

Thats the basic note which covers all billing and things. Just as important is you need to use your knowledge to understand the disease at hand and incorporate information that is pertinent to the medical decision making.

For instance here is an MVC note which is similar.

<Age> year old <sex> with PMH of <blank> presents to the ED <via EMS/MedAir (helicopter people)> for evaluation s/p <single?> MVC (or motorcycle crash, assault, bicycle crash etc). This patient was in their usual state of health (this implies no prior symptoms which caused the wreck) until <time of incident> when, while acting as a <restrained?> <driver/passenger> moving <velcoity>, <he/she> was involved in a <type of collision> collision with impact to their <where the car was hit (driver side door?)> and <negative/positive> LOC. EMS report at scene: <ambulatory?>, <GCS ?>, <hemostatic?>, <did the car roll?>, <was the patient entrapped?>, and etc. Medic reports en route: <highest HR>, <lowest BP>, <BGL (if you want)>, <O2 sat if necessary>, others. This patient was administered <drugs given if necessary>. <Does the patient have abrasions?> <Does the patient report pain> <Does the patient have pressing medical problems which are necessary to add to the note (not likely in trauma note but on occasion)>. A complete history is limited by the patient's current clinical condition.

Essentially you need to pick up on what details need to be added. an MVC note requires different info than a dialysis problem (last dialysis session? was it full? etc.) cancer patient (whats the status of that disease? last chem/radiation? complicated by metastasis?)

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STEP 3: Review your notes from the past shift and as you go.

The only way you can get better is being objective with your own performance. The interesting thing about being a scribe is that you get objective feedback 20+ times a day. At the end of your shift (and throughout) you need to be going through the EMR program and make a mental checklist of what info you left out, and what info the provider edited. I can't stress enough that this is the only way of getting better. The other option is asking your resident for feedback, but at my institution it seems like some residents are too nice (they probably wouldnt call my note sub par even if it was).

Ok thats everything I can think off.

Info you need. You guys should add some other diseases and cases to this to help us out.

Include these if given.

(of course add in the HPI elements so it bills well)

MVC

  • LOC?
  • mechanism of crash
  • restrained? (helmet for motorcycle)
  • head/neck trauma/pain?
  • speed of car
  • airbag deployment
  • damage to car? (especially if the car was very damage with intrusion)
  • highest HR
  • lowest BP
  • O2 sat
  • medications administered by EMS (pain killers like fentanyl as well)
Falls

  • LOC?
  • acute onset symptoms prior to fall? (lightheaded?)
  • Why did they fall? trip? legs go out from weakness? legs go numb? (dont use the word mechanical fall, it triggers me)
  • from what height did they fall? (standing? 40 ft?)
  • what did they fall to? (hard surface? ground? did they hit things on the way down?)
  • where does the patient live? (SNF? assisted living? independent living? etc) Typically add this because old people
Dialysis problems

  • Last dialysis
  • full treatment? Was the treatment cut short? Why? Hypotension? did feel like staying?
  • look through past notes. is the patient frequently non compliant?
  • what is the dialysis schedule? Where do they get dialysis?
Psych problems

  • suicidal ideations at evaluation? More specifically do they have plans to harm themselves?
  • plans to harm others?
  • possibly include a statement about the patient's demeanor. Are they pleasant? Are they compative?
  • The EMS report is important here. Is the patient taking more meds than prescribed?
  • this stuff is obvious. if it sounds concerning take a note of it.
Chest pain

  • cardiac history?
  • obvious stuff including risk factors, radiation, nausea etc.
  • last cardiac testing. stress test?
  • on blood thinners?
  • other stuff im forgetting
Syncope

  • prior symptoms?
  • prior episodes?
  • duration of time LOC?
  • other stuff
Ill comment other diseases when i get the motivation. Theses are just the main ones

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STEP 4: Actually sitting down at the computer after seeing the patient.

First things first. You need to go through the patient's recent medical history. This is a must. Find pertinent information and include it if its useful. Patient is in for a GI issue? Oh ****, they have a GI note from 2 days ago. what were the findings, what was discussed?

THEN write the note. the actual writing of the note should come after a 4min(or less) research of the patient's records. If your ED's triage is good then they will already have a decent history laid out.

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STEP 5: Leaving information out

With experience you should be able to get a read on the physician. If the patient comes in with 3 complaints and the Dr wants to cut it down to 1 or 2. Just leave it out. You can ask the Dr if you aren't sure. When in doubt just ask.

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STEP 6: Finishing the note and downtime.

You are done with all your current notes? proof read ----> go through the patient's PMH to see if you have better info to include ----> keep an eye on the trackboard for new patients (get the note ready before the physician wants to go, go ahead and start looking at the patient's PMH, start the note with info you already know) ------> discretely browse /r/premedand chat with the med students if they look bored too.

OK I think thats it. Basically to sum it up.

  1. Say hello to the resident or whoever. just do it.
  2. write the note however you want. you dont have to do it my way. The point is you should find a system that is fast. thats the name of the game. Fast notes and good notes.
  3. Review your past notes so you can improve. Poll the residents if you want at the end of the shift.
  4. Review the PMH before writing the note. you need to put in relevant info. the HPI is not just the 5min interview
  5. Get experience/ ask the Dr before leaving info out at your own discretion
  6. Always make sure the notes are right before dicking around
 

alpinism

Give Em' the Jet Fuel
7+ Year Member
Nov 6, 2011
3,105
2,768
Port Au Prince
  • LOC?
  • mechanism of crash
  • restrained? (helmet for motorcycle)
  • head/neck trauma/pain?
  • speed of car
  • airbag deployment
  • damage to car? (especially if the car was very damage with intrusion)
  • highest HR
  • lowest BP
  • O2 sat
  • medications administered by EMS (pain killers like fentanyl as well)
IMO you don't need all that VS info in the HPI unless the pt is being resuscitated.

In MVA pts all I care about is time, mechanism, speed, restrained, airbag deployment, and if they were ambulating at the scene.
After that its all about ruling out life threatening pathology = Any LOC, weakness, or numbness? Any severe pain, vomiting, or difficulty breathing?