Scribe Advice

[CurryBear]

I posted on here before about being a scribe and I have another question. Do any of you guys write the full plan for the doctor in the DAP section of the chart? We use NEXTGEN and at the bottom of the chart I'm supposed to fill in the assessment and plan based off what the doctor says during a patient visit but I'm unsure what to write. I've been working there since March and I get everything else in the chart besides writing up a plan for the patient's diagnoses and conditions. The doctor doesn't say it out loud so I am left guessing what to fill in under each diagnoses. If they doctor does say it out loud then I write down what he says but he adds a bunch of stuff later that I had no idea I was supposed to put in. Or the worst is he doesn't say anything out loud and I am completely blank minded on what to write, leaving ME to diagnose and treat the patient with the random knowledge I have. I always try filling it in but it's wrong most of the time and the doctor seems pissed off that he has to delete everything. If I leave it blank and let the doctor do it then he seemed frustrated that I didn't write anything or understand what he said in the patient room. I am not sure what to do, how do you guys handle this? Do you write the entire plan? How? What is your doctor like?

Thanks.

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[AccessoryNavicular]

One of the things I learned in my scribing experience is if you don't know something, ask. It might be useful for you to sit down with the doctor you work with and discuss these issues so that he has a better understanding of your limitations as well as some of the areas that he needs to do a better job at.

 

[wanderingorion]

Definately ask, as AN said. But, you will learn the plans after seeing the same conditions over and over. It just takes time.

 

[Espressso]

It's all dependent on the specialty you're working in. And then it's also completely dependent on the doctor you work with. I work in an Allergy/Immunology clinic, so our patients are either suffering from basic allergies and asthma, or complex immunodeficiencies. But after a while, you get the hang of the patient instructions, i.e. dosages for common medications that are prescribed, physician recommendations about lifestyle changes, etc.

But yeah, the main rule of thumb here is to always ASK THE PROVIDER! They know the answers to all your questions!

 

[thatwouldbeanarchy]

Agree, you have to ask! Not all doctors will expect the same of you. In my experience, some doctors would dictate aloud to me what they wanted me to document for their Assessment/Plan or Medical Decision-Making. Others preferred to do that part themselves. But I've never heard of scribes writing up their own diagnosis/plan. Not a good idea.

Even when a doc would dictate and I would write down what they said word for word, some would still go back later and add an addendum as aspects of the patient's care plan may have changed.

Bottom line: definitely DON'T guess! Over time, you may develop a routine with certain providers and certain conditions. But it's always better to ask than to assume. You don't want to you or the doctor to be liable for incorrect (and potentially dangerous!) documentation in a patient's chart.

 

[Tabiyou]

For context, I worked as an ED scribe for 1.5 years. Something I always did at the beginning of my shift was politely ask the physician how they liked their charts. As they began to reflect they would tell me if they had macros or would want their HPI,ROS a specific way. During a lull in the shift, I would politely ask them if they could look at one of my charts and ask for any recommendations.

Please note some physicians will not be direct or rely on CS to communicate feedback rather than telling you.

I know some providers get upset when you ask multiple questions. I've been in your shoes, its best just to ask the provider questions as the shift goes along.

 

[----x----]

The role of a scribe is to document care as they observe it in the room, as told to then, or read it in chart review when summarizing a patient's history. This can include the entirety of the note, from HPI to A&P/MDM. It's really not dangerous for a scribe to write the assessment and plan as long as it's gone over explicitly in the room, with clarifications made later. It would be more dangerous in an ER setting where these discussions usually don't take place with the scribe present, so dictations are needed.

A scribe shouldn't need any advanced medical knowledge whatsoever to function at a basic level, but would be improved significantly the more they know about where they are charting in. Some basic terminology is needed just to get the right words down, but the medicine/science behind it is not.

As soon as a scribe is tasked with thinking independently, requiring their own medical knowledge to create the note, they are overstepping their bounds and qualifications.
If it isn't said in the room, isn't said to the scribe, and isn't in charts to review - then it won't get in the note. That's how I run the scribe program I'm at, and how I frame provider's expectations of having a scribe when we bring a new program to an ER/clinic.

 

[jtd2081]

Always ask if you don't know something. I can't stress that enough. Being relatively new you are bound to now understand everything that happens. It all takes time. Soon you will know exactly what is going on for most of the patients. Just takes a little time. All the docs I work with are really chill people. Just normal people who happen to be doctors. No god complexes or anything. You asking them a question about the charting is better than potentially writing something wrong down because it is essentially their chart you are writing in, so just be weary of that. I have been working as a scribe for over 2.5 years, and work with the same 5 or so docs so they generally trust me to put something into the medical decision making (we use CareConnect) to ensure that the coders and people reading the chart know what is going on. It does not sound like you are quite there yet so please just ask the provider.

 

[Krooskie]

I work in a hospital ED as a scribe so the situation is a little bit different I imagine but I agree with the posts above me. Always ask. However, once you get the swing of things a bit, you can phrase the question in different ways and make it easy on the doc by saying something like "in this section, would you like me to put (some assessment and plan that you guessed/made up) or something different?" That way, if you're right, they just have to say "yes" and then move on with other tasks but you've provided them an opportunity to correct you in case they have a different plan.
As you get more experience, it gets easier to guess the right information so the doctor just has to approve it.