ER Scribe advice

[orangeman25]

---

Members don't see this ad.

Okay, so from those experienced scribes, I need advice. Have you ever worked with a really fast physician? I'm talking she's in the room with the patient such a short time. Dispos patients really quickly and speaks incredibly quickly.

How do you handle such physicians besides the obvious of telling them to slow down? Because I can't tell her to slow down. She sees like 30 patients in an 8 hour shift it's crazy.

 

[SweetCaroline7]

Yes. We had 2-3 physicians that were notoriously difficult to work with and only certain scribes were approved to work their shifts. A few questions before I offer advice:
1. Do you have Notepad available to you on your computer?
2. Do you use an active patient list?
3. Do the physician's preferences require that the chart be ready to sign at disposition, or just before the end of the shift? Obviously if the patient is going to ICU or OR, you'll need to have the chart done ASAP, but I'm talking about the majority of cases, for discharge or standard admission/observation.

 

[orangeman25]

Yes. We had 2-3 physicians that were notoriously difficult to work with and only certain scribes were approved to work their shifts. A few questions before I offer advice:
1. Do you have Notepad available to you on your computer?
2. Do you use an active patient list?
3. Do the physician's preferences require that the chart be ready to sign at disposition, or just before the end of the shift? Obviously if the patient is going to ICU or OR, you'll need to have the chart done ASAP, but I'm talking about the majority of cases, for discharge or standard admission/observation.

1. Yes we do have a word professor available but I don't use it
2. I'm sorry but I'm not sure I know what an active patient list is? Can you describe it?
3. Charts need to be signed at the end of the shift, not at dispo. For some docs it depends and they like signing charts at dispo, but not the doc I'm talking about

 

[Cookieee]

I had this problem when I was starting out as well. You will eventually get used to the pace but here are some tips that I hope help:

- Have notepad open on the side to type your notes and later transfer them to the designated categories of the EMR. At the same time, have the chart open and start typing there as well. For example, if you are typing the HPI and the doctor is doing the physical exam, it makes it easier to just throw the PE to the side instead of switching tabs on the EMR and losing your train of thought.
- Learn and use abbreviations! So much easier to type EOMI than "extraocular movements intact"
- Don't type normal exam findings. After working with a certain doctor, you figure out what their "normal" PE looks like. Don't type out "abdomen nontender, no guarding, etc" remember that the "abd" was "nml." This makes it easier to catch the important, abnormal findings!
- Forget the fluff until the end. Type up things like, "45 year old female" at the end or later. If the physician is announcing this and then speeds into the PE, you'll be behind!
- Google is your friend. I always write words the best I can and look up the terms or drug later.
- Don't be afraid or embarrassed about asking them to repeat themselves. They are so trained in using this language, they often forget we are typing it and end up letting out a stream of thoughts! I know one physician who just mumbles without pausing, totally lost in his own head. I usually end up asking him once we leave the room (so he doesn't forget) to repeat what I didn't catch.

 

[orangeman25]

I had this problem when I was starting out as well. You will eventually get used to the pace but here are some tips that I hope help:

- Have notepad open on the side to type your notes and later transfer them to the designated categories of the EMR. At the same time, have the chart open and start typing there as well. For example, if you are typing the HPI and the doctor is doing the physical exam, it makes it easier to just throw the PE to the side instead of switching tabs on the EMR and losing your train of thought.
- Learn and use abbreviations! So much easier to type EOMI than "extraocular movements intact"
- Don't type normal exam findings. After working with a certain doctor, you figure out what their "normal" PE looks like. Don't type out "abdomen nontender, no guarding, etc" remember that the "abd" was "nml." This makes it easier to catch the important, abnormal findings!
- Forget the fluff until the end. Type up things like, "45 year old female" at the end or later. If the physician is announcing this and then speeds into the PE, you'll be behind!
- Google is your friend. I always write words the best I can and look up the terms or drug later.
- Don't be afraid or embarrassed about asking them to repeat themselves. They are so trained in using this language, they often forget we are typing it and end up letting out a stream of thoughts! I know one physician who just mumbles without pausing, totally lost in his own head. I usually end up asking him once we leave the room (so he doesn't forget) to repeat what I didn't catch.

Thank you! Very good tips all around. I'm going to start making my own abbreviations for sure. And I really like the part about not even typing normal exam findings as long as I remember it was normal.

 

[SweetCaroline7]

An active patient list is something we made our trainees use throughout training, or they couldn't pass, so I think it is extremely helpful. Basically, it's a sheet of paper that has a bunch of rows and columns, with the columns being name, CC, HPI, ROS, PEx, EKG, MDM, Consults, Notes, Dispo. You can make a sheet like this and use the table function in Excel so that the rows are lined, then make a bunch of copies. When you get a new patient, write Last name, First initial, then wait to write everything else until after the initial visit.

So here's how it works. Say we are in the row for John, D. Column by column, you put a circle in each cell as you start to work on each element of the chart. When you complete that element, you put a check mark inside the circle. You DO NOT, under any circumstances, put a check mark in a circle that you are not 100% comfortable with turning into your physician. Even if you just want to tweak the wording a little, but the info is all there and technically "ready" to go, if you wouldn't have your doc sign it that way, don't put a check mark! I always trained people to put the check mark there when they are so sure that the section is complete that they aren't even going to double check it when the chart is finished. So, you finish out the row for John that way, through disposition, and when all of the cells have a circle with a check mark and you're ready for signing, you put a line through John's row. The particular physician that I'm thinking of as I'm answering your question knew that if I had a line through that patient's name, he could sign the chart. (I had the piece of paper on the desk between us when he would review charts).

Now, I know this seems like it doesn't really do much to help you pick up info that is flying at you at top speeds, but I do agree with the other poster who said that you will pick up more with time. The magic of the active patient list is that you don't have to second guess your work, and once you learn how to use it properly, you will free up so much of your time that is probably currently spent on omg-so-much-info-must-triple-check-that-I-didn't-forget-that-one-symptom. You will also feel a lot more confident that your chart isn't missing any pieces if you use the list properly. That was one of the things that stressed me out the most during a shift with a fast-paced physician, so I loved the active patient list.

As far as the notepad, I actually asked because I saw a lot of newer scribes use it TOO much. You're potentially spending so much time typing info into that when you could be typing it into your chart. It's not going to look nice, but why even spend the time copying and pasting the info later. I hastily typed anything I heard ANYWHERE I could, but in the chart. When you are typing with one hand while run-walking to the next room and your doc is telling you symptoms left and right, it's just easier not to even have to worry about the 30 seconds you lost transferring the info.

 

[Mr Roboto]

Yeah, there's a few providers in our ED that work fast like that. Typically only more experienced scribes work with them, because it's a lot to handle in the beginning.

Have as much of the documentation completed as possible before you get into the room.

Finish the HPI before leaving the room. Also prewrite as much HPI as you can before entering the room--age, sex, PMH, any info on the cc drawn from nursing/triage/EMS notes (onset, severity, constancy, duration, tx PTA, pertinent denies, etc. are often present in my experience).

I take notes in a word processor if the doc speaks faster than I can dispo. I might type something like "Jones [admitting doc] on telemetry w/ dx CHF, hypokalemia, weakness, sob" or "D/c home, improved, dx viral syndrome, flup w/ pcp 1-2w as needed." Then while they're working on something else I'll put that into the EMR.

If you have Microsoft word on your computer you can set up shortcuts for typing. Create your own abbreviations and have autocorrect change them into the longer phrase/words. This was especially useful to me for common exam findings.

Good luck, the best advice is to keep at it 🙂 in a few shifts you'll forget it was ever a problem for you.

Okay, so from those experienced scribes, I need advice. Have you ever worked with a really fast physician? I'm talking she's in the room with the patient such a short time. Dispos patients really quickly and speaks incredibly quickly.

How do you handle such physicians besides the obvious of telling them to slow down? Because I can't tell her to slow down. She sees like 30 patients in an 8 hour shift it's crazy.

 

[orangeman25]

Thank you all for the wonderful advice. It sounds like you all have passed the "omg this is overwhelming" phase and into the "wow this stuff is actually cool." I hope to get past all the technicality and adjustment aspects of the job so I can start enjoying why I really wanted to scribe in the first place. Some of the really experienced scribes at my hospital are whizzes and basically treated as residents because they have worked for so long (>2 years). So jealous of them.

Anyways, cheers!

 

[TeddyRuxpin'sTeddy]

Glad we could help, and enjoy the process!

 

[Mayday_]

Am I the only one here who doesn't take the computer with me into each patient room? Where I work we just take notes on paper and type it up later.

But I agree with @SweetCaroline7 . Having your patient tracking down will make things soo much easier. That way if you get behind, it's okay because you know exactly what you still have to complete (Another reason that taking notes on paper works for me, I have it all even if I'm behind on my charting).

It does get easier with time though! Hang in there 🙂

 

[mehc012]

Sounds like you got your answer, but for the sake of discussion I'll just add my 0.02.
I typically make it my goal to have the HPI and ROS done before we leave the room and have the physical open and ready for the physician to dictate as we're walking to our next patient/to go put orders in. That way the next time you touch the chart after leaving the patient's room will be for re-evals, procedures, or finishing up the disposition details. This works well for me.

It gets easier, trust me. You'll find out the order you like your HPI's to be in. Mine, for example starts with a dot phrase that brings in the pt's info, so .open = "<name> is a <age> <gender> with <chiefcomplaint>" followed by description/severity/quality/onset, modifying factors, pertinent associated symptoms (you learn what's relevant the more patients you see), and a little context if it's relevant. Our PMHx and PSHx and FMx is pulled into the chart automatically right below the HPI, and we modify that if something important isn't in there. So for example;

Sally is a 18y/o female which chief complaint severe Abdominal Pain (described as stabbing) in the RLQ onset 1400. Worsened by movement. +N/V. +Diaphoresis. No diarrhea/constipation. No dysuria. No fever. LMP 7/8.

Luckily sometimes the fast doctors get slowed down doing a laceration repair or something, so this is the time to go over your charts with a fine-tooth comb and make sure there's nothing glaring you're leaving out. Good luck to you!

Wait, you'd seriously leave your HPI in that format? And get away with it?

Ours are stand-alone...all pertinent medical history included, complete sentences, preferably good flow and plenty of details.

 

[ems2doc]

I shadowed a pediatrician who saw an average of 40 patients per day. Usually the nurse spends 15 minutes or so with the patient and then the doc sees them for about 10 minutes to do a quick physical and go over the basic health history. He stays with patients who have actual complaints (not just regular checkups) for longer. Also, some docs see multiple patients at the same time by visiting with one patient while another is getting tests done or something.

 

[Mr Roboto]

Likewise. The physicians pay us to document them in a clear manner. If we write them like that ^ then they might as well be using statdoc forms.

Wait, you'd seriously leave your HPI in that format? And get away with it?

Ours are stand-alone...all pertinent medical history included, complete sentences, preferably good flow and plenty of details.

 

[Mayday_]

Wait, you'd seriously leave your HPI in that format? And get away with it?

Ours are stand-alone...all pertinent medical history included, complete sentences, preferably good flow and plenty of details.

Some places don't have specific requirements. The company I work for used to have scribes input it like that and then click or backslash everything which ends up giving it a weird, choppy format.

Now we type out fully:

"34 year old female, with a history of blah blah blah, presents to the emergency department with complaints of epigastric abdominal pain onset 3 days ago with associated nausea and vomiting. Patient also complains of dysuria and fever, but denies back pain."

Even now, some providers don't care one way or another, but it just sounds so much prettier when typed out fully. 😛 I suppose it just varies between companies or providers.

 

[clavicle]

.

 

[Scribblers]

A large part of getting faster at charting is also anticipating the types of questions a physician is going to ask for a given presentation. An H&P for nausea/vomiting/diarrhea is generally going to be fairly similar every time, so once you get used to including +/- fevers, recent foreign travel, sick exposures, recent antibiotics, unusual foods, etc. you'll just automatically listen for those things and have more focus to actually type the history or physical.

 

[mehc012]

Some places don't have specific requirements. The company I work for used to have scribes input it like that and then click or backslash everything which ends up giving it a weird, choppy format.

Now we type out fully:

"34 year old female, with a history of blah blah blah, presents to the emergency department with complaints of epigastric abdominal pain onset 3 days ago with associated nausea and vomiting. Patient also complains of dysuria and fever, but denies back pain."

Even now, some providers don't care one way or another, but it just sounds so much prettier when typed out fully. 😛 I suppose it just varies between companies or providers.

Even that would be pushing it on the brevity side at my site, though yes, it does sound much better.

As a note, my place has no specific requirements, other than meeting coding levels. Many of my DOCS, on the other hand, go through the charts with a fine-toothed comb.

 

[Mayday_]

Even that would be pushing it on the brevity side at my site, though yes, it does sound much better.

As a note, my place has no specific requirements, other than meeting coding levels. Many of my DOCS, on the other hand, go through the charts with a fine-toothed comb.

Well I mean obviously a provider would ask more than that and I would include it. I was just giving an example of the format


Edit: I forgot to insert the quote. Oops

 

[orangeman25]

I always have difficulty deciding which aspects of the medical history to include in the HPI, especially when the pmh is extensive for the patient. Those are instances where I actually wish I knew more about medicine 🙁

 

[Mr Roboto]

It comes quickly 🙂

I always have difficulty deciding which aspects of the medical history to include in the HPI, especially when the pmh is extensive for the patient. Those are instances where I actually wish I knew more about medicine 🙁

 

[orangeman25]

Guys sorry to bring this thread back but I have another question:

Does anyone have a good resource for knowing critical lab values? On our EMR, it just says high or low and doesn't have parameters.

 

[mehc012]

Guys sorry to bring this thread back but I have another question:

Does anyone have a good resource for knowing critical lab values? On our EMR, it just says high or low and doesn't have parameters.

Just Google it. Not joking. If it's labelled high or low, google the normals. You'll learn them pretty quickly.

 

[Soviet Poland]

I always have difficulty deciding which aspects of the medical history to include in the HPI, especially when the pmh is extensive for the patient. Those are instances where I actually wish I knew more about medicine 🙁

That really just comes with time. When I first started out, I'm sure my charts were choppy and unorganized, as I'd kind of just write everything down. Especially when patients would ramble.

Eventually, you see so much of a presentation, you know what to include. When starting out, keep it simple. Keep similar organ systems together or similar onsets together. A patient coming in with flank pain, it's more pertinent to know if they have a history of renal stones than say COPD. Their entire medical history is important, but for the HPI, you really only need to include what brought the patient to the ED. The rest can go in whatever section of your EMR deals with Past Medical, Family, Social history.

To increase speed, focus on just the key billing elements for an HPI.

For example, my routine is usually opening a chart based off of the nurse's triage note, preferably before we go into the room. I start adding all the click boxes and throwing in my "macros" (saved templates) to create the backbone of the chart. I've done it so many times, it's effortless, so my attention is mostly focused on those HPI billing elements. Chief complaint, onset, timing, duration, location, modifying factors, associated symptoms, etc.

 

[GaiusOctavius]

Know the associated symptoms for each chief complaint PERFECTLY. As soon as you go into the room and realize cc, begin typing HPI with pertinent positives or negatives. Just listen to what is positive and mark negative for everything else. If you don't know which associated symptoms you are looking for, it will be difficult to remember everything that was said. You improve with practice. If the physician is moving too fast, kindly explain that you are new and request that he/she give you a second to finish an aspect of the chart before moving to the next room. If they give you a hard time about it or are blatantly rude, report it to your superior...

 

[Mr Roboto]

This site is a goldmine. Click around on it for a while to understand way more about what you're writing. Trying to remember the site I used to learn basic labs, will post if I recall it.

http://meded.ucsd.edu/clinicalmed/introduction.htm
http://meded.ucsd.edu/clinicalmed/links.htm