Scribes in the ER

[hopefulERdoc251]

Hey ya'll, new attending here. Looking for some advice on how to best maximize scribes.

Our group uses scribes and trains their own scribes and they def are pretty good at charting etc and capturing the key components of billing for the new coding/billing guidelines. I'm struggling with the workflow of using scribes. In residency - I would see a patient, chart a brief MDM and as labs came in and imaging came in, I would document them and "run my list" from top to bottom to make sure I wasn't missing anything. Our scribes will ask for imaging/ekg/lab interpretations while I'm doing other things (maybe chart reviewing another patient, etc) and it causes me to pivot and lose track of what I'm doing (thanks ADHD). In my first few shifts, I've found that by doing this, I end up not having a great grasp on the nuances of my patients and I feel like I'm running around like a chicken with its head chopped off and it's affecting my efficiency/makes me afraid that I will miss something.

Any useful tips on how to maximize scribes? I was going to trial telling the scribes that I will "run my list" every half hour or so to catch up on all those labs etc that way I'm also reviewing everything but I'm not sure if that'll be effective. Thanks!

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[RustedFox]

Dont use them at all.
Anything I can say into a microphone is faster and more accurate.

 

[BoardingDoc]

I've never understood the appeal of scribes if you've got dragon. I really also don't need or want some kid following me around into each patient room and then sitting next to me just staring at me if I'm not talking to them as I then either have this socially bizarre situation, or I'm pushed to make small talk with them...which wastes time ... Which defeats the entire purpose of having a scribe in the first place.

 

[Druggernaut]

I recently took a new job and working with scribes for the first time. They just do the history, +/- ROS, I click a macro for a normal physical exam then modify as needed, and dictate my own MDM and ED course. They'll also usually do some sort of chart review to help with clicking the box of "reviewed records" for billing purposes.

I don't think I'd use them if they were costing me $15-$20/hr like some CMGs do, but they're built in to the structure at the SDG here and apparently are only paid minimum wage since they're almost exclusively pre-med and pre-PA looking for exposure and recommendation letters.

 

[EM Junkie]

15 years out of residency and the highest biller in our multi-hospital system.

Scribes are a waste of time. Sure some are great, and most of them are nice people. Keep in mind the time you take to review what they typed and time chatting with them is wasted time that you could be seeing more patients and making $$. Also some of them want to get letters for med school applications and think they make themselves look good by asking a lot of questions.

If they’re forced upon you, use them to bring discharge papers out to the nurse or run down ECGs.

My workflow is as follows:
Sign up for patient
Brief chart review (triage notes, vitals, history, and prior visits)
See parient
Chart HPI, ROS, and PE as soon as possible
I will keep an eye out for labs, imaging, etc but don’t interpret or document on tjhem until patient is ready for dispo
When patient is ready for dispo, I comment on labs/imaging, complete MDM, and dispo patient
I won’t sign chart until I get downtime, then will go through 5-10 charts at a time to review everything, make sure CC time is documented, and sign/close the chart.

 

[Tiger26]

I think scribes only work when you're at a certain level of busy that you're going from room to room or when you're so dysfunctional that you have trouble putting in a note (think about that 50+ age guy in your group who can't figure out how to get email on his phone ...)

With dictation and knowing my macros well, I can write a fairly thorough note in about 2 min.

That said, in my limited experience with them, I found that I had to explicitly verbalize everything that I was thinking in the patient room or afterward. Otherwise, it wouldn't end up in the note.

 

[TooMuchResearch]

They are not helpful other than writing an incorrect history, interrupting me, and screwing up the time-stamped information they are supposed to capture.
I do not review their HPI because that would nullify any possible time savings they offer.
I have attempted to stop using them and was told I am required to use them.
I send them home early whenever feasible.
I would happily stop using them tomorrow.

 

[TooMuchResearch]

Hey ya'll, new attending here. Looking for some advice on how to best maximize scribes.

Our group uses scribes and trains their own scribes and they def are pretty good at charting etc and capturing the key components of billing for the new coding/billing guidelines. I'm struggling with the workflow of using scribes. In residency - I would see a patient, chart a brief MDM and as labs came in and imaging came in, I would document them and "run my list" from top to bottom to make sure I wasn't missing anything. Our scribes will ask for imaging/ekg/lab interpretations while I'm doing other things (maybe chart reviewing another patient, etc) and it causes me to pivot and lose track of what I'm doing (thanks ADHD). In my first few shifts, I've found that by doing this, I end up not having a great grasp on the nuances of my patients and I feel like I'm running around like a chicken with its head chopped off and it's affecting my efficiency/makes me afraid that I will miss something.

Any useful tips on how to maximize scribes? I was going to trial telling the scribes that I will "run my list" every half hour or so to catch up on all those labs etc that way I'm also reviewing everything but I'm not sure if that'll be effective. Thanks!

Don't let them interrupt you.
If you need to put all results into notes, find a way to automatically do it through the emr.
Tell them to never interrupt you.
Send them for any menial task you think they can do which is understandably very little.

 

[RustedFox]

I had a really good thread on this awhile back entitled: "Do your scribes suck?" or something similar.

 

[always.chillin]

I work for a system with scribes. I don't use them because I'm faster without. Literally takes 1 min to dictate an H&P. You would think the hospital would add on $15-20/hr for not using the scribe but nope.

 

[GatorCHOMPions]

The change from the scoring of H&P/ROS to emphasis on MDM for billing has made scribes even more obsolete.

 

[JacobMcCandles]

You can button up a fantastic chart in 2 minutes or less. I’ve never used scribes but I don’t see how they wouldn’t create unnecessary work.

 

[dozitgetchahi]

I think scribes only work when you're at a certain level of busy that you're going from room to room or when you're so dysfunctional that you have trouble putting in a note (think about that 50+ age guy in your group who can't figure out how to get email on his phone ...)

With dictation and knowing my macros well, I can write a fairly thorough note in about 2 min.

That said, in my limited experience with them, I found that I had to explicitly verbalize everything that I was thinking in the patient room or afterward. Otherwise, it wouldn't end up in the note.

This.

As a rheumatologist, I have worked both with and without scribes.

If you have Dragon and a *good* EMR that has the full ensemble of templates, dot phrases etc (Epic, Cerner and others) then I agree there is little to be gained from having a scribe.

If you have a **** EMR that doesn’t template well and can’t do macros (Meditrash, Centricity, etc etc) and/or you don’t have dictation software, then maybe there is some benefit to having the scribe. The only time a scribe saved me time was when I was working with awful EMRs that couldn’t do these things.

Aside from that, I agree with the social awkwardness aspect as well as having to speak out every single freaking detail of your visit to the scribe as you do it. Verbally talking out a physical exam of 20+ joints to a scribe (which you have to do as a rheumatologist) was exhausting and time consuming. Also…it takes forever to “train” the scribes to do what you want them to do, and then they leave. A lot of them are premeds and they will bail out frequently for med school interviews and such, and then leave altogether for medical school when they get in. My time with a scribe was a revolving door of just getting to the point where the scribe was actually helpful, and then having them gone 50% of the time for medical school interviews, and then leaving…wash rinse repeat. (My employer at the time didn’t provide an alternate scribe when my scribes were out doing interviews, and they were very slow to find replacement scribes after one left…so I basically didn’t have a scribe much of the time anyway.) To make a scribe useful, you basically have to change your workflow dramatically to integrate them, and then if they’re not there everything is messed up. It’s just way easier to not have to deal with them.

I use Epic and Dragon now and I don’t have a scribe…I’m faster than I’ve ever been.

 

[gutonc]

I think scribes only work when you're at a certain level of busy that you're going from room to room or when you're so dysfunctional that you have trouble putting in a note (think about that 50+ age guy in your group who can't figure out how to get email on his phone ...)

With dictation and knowing my macros well, I can write a fairly thorough note in about 2 min.

That said, in my limited experience with them, I found that I had to explicitly verbalize everything that I was thinking in the patient room or afterward. Otherwise, it wouldn't end up in the note.

This is kind of how I feel as well. The only people I know who find scribes irreplaceable are the ones who took Step 3 with a #2 pencil and type on a computer keyboard with 2 fingers.

I personally don't even find Dragon all that much more efficient for me than a decade's worth of Epic templates and smartphrases and a pretty blazing typing speed. I'm about to dive into Dax Copilot on Epic to see if that's any more useful.

 

[emergentmd]

If you have a decent EMR/Dragon, they are useless. I have only had one place with scribes and they were just good for clicking stuff. I did a quick History/MDM on all of them. I didn't pay, so I was fine giving them a job. But I would never pay for one unless I was still doing paper charting.

 

[bky3c]

They are not helpful other than writing an incorrect history, interrupting me, and screwing up the time-stamped information they are supposed to capture.
I do not review their HPI because that would nullify any possible time savings they offer.
I have attempted to stop using them and was told I am required to use them.
I send them home early whenever feasible.
I would happily stop using them tomorrow.

I agree with all of this except for not reviewing the HPI, only because I worry about medicolegal landmines. The only times I've found them useful have been when I've had a million family members all in one room, all for one benign thing, and then the scribe could waste their own time instead of mine copying and pasting most of the chart. If you can possibly work without them, do it. Someone should do a study on EP efficiency with/without scribes so the C-suite will stop forcing them on us.

 

[TooMuchResearch]

This is kind of how I feel as well. The only people I know who find scribes irreplaceable are the ones who took Step 3 with a #2 pencil and type on a computer keyboard with 2 fingers.

I personally don't even find Dragon all that much more efficient for me than a decade's worth of Epic templates and smartphrases and a pretty blazing typing speed. I'm about to dive into Dax Copilot on Epic to see if that's any more useful.

If Dax Copilot is this new thing that inefficiently does a chart review for you, I can tell you it's unlikely to help your workflow in the current form.

 

[TooMuchResearch]

I agree with all of this except for not reviewing the HPI, only because I worry about medicolegal landmines. The only times I've found them useful have been when I've had a million family members all in one room, all for one benign thing, and then the scribe could waste their own time instead of mine copying and pasting most of the chart. If you can possibly work without them, do it. Someone should do a study on EP efficiency with/without scribes so the C-suite will stop forcing them on us.

I'm not worried about medicolegal landmines.

 

[RustedFox]

This.

As a rheumatologist, I have worked both with and without scribes.

If you have Dragon and a *good* EMR that has the full ensemble of templates, dot phrases etc (Epic, Cerner and others) then I agree there is little to be gained from having a scribe.

If you have a **** EMR that doesn’t template well and can’t do macros (Meditrash, Centricity, etc etc) and/or you don’t have dictation software, then maybe there is some benefit to having the scribe. The only time a scribe saved me time was when I was working with awful EMRs that couldn’t do these things.

Aside from that, I agree with the social awkwardness aspect as well as having to speak out every single freaking detail of your visit to the scribe as you do it. Verbally talking out a physical exam of 20+ joints to a scribe (which you have to do as a rheumatologist) was exhausting and time consuming. Also…it takes forever to “train” the scribes to do what you want them to do, and then they leave. A lot of them are premeds and they will bail out frequently for med school interviews and such, and then leave altogether for medical school when they get in. My time with a scribe was a revolving door of just getting to the point where the scribe was actually helpful, and then having them gone 50% of the time for medical school interviews, and then leaving…wash rinse repeat. (My employer at the time didn’t provide an alternate scribe when my scribes were out doing interviews, and they were very slow to find replacement scribes after one left…so I basically didn’t have a scribe much of the time anyway.) To make a scribe useful, you basically have to change your workflow dramatically to integrate them, and then if they’re not there everything is messed up. It’s just way easier to not have to deal with them.

I use Epic and Dragon now and I don’t have a scribe…I’m faster than I’ve ever been.

even Meditrash (lol) has a Marco work-around now built in.

Every heading (HPI, PE, MDM, etc) has a "free text only" field, and you can command-phrase your way thru.

Click HPI.
say: "ZIP COPD exacerbation"
Click PE.
say: "ZIP COPD exam"
Click MDM.
say: "ZIP COPD ADMIT".
Click Dispo.
say: "Bye Felicia!" (yes, I really set that up)

There. I'm done.

 

[dozitgetchahi]

even Meditrash (lol) has a Marco work-around now built in.

Every heading (HPI, PE, MDM, etc) has a "free text only" field, and you can command-phrase your way thru.

Click HPI.
say: "ZIP COPD exacerbation"
Click PE.
say: "ZIP COPD exam"
Click MDM.
say: "ZIP COPD ADMIT".
Click Dispo.
say: "Bye Felicia!" (yes, I really set that up)

There. I'm done.

Yeah I’ve heard that newer versions of Meditech are somewhat more useful.

Back when I was stuck using it, it had that 1980s style black screen command prompt and wasn’t able to do all sorts of things that other EMRs had been doing for years. Truly “Meditrash”. Cheap ass hospitals like it because it’s cheap. But it’s ****.

 

[gutonc]

If Dax Copilot is this new thing that inefficiently does a chart review for you, I can tell you it's unlikely to help your workflow in the current form.

No, it's basically an AI scribe that is Epic native.

I don't even trust final year fellows to do a chart review for me...I mean, I let them do it, but I do it myself too. There's no way I'm letting ChatGPT do it.

 

[RustedFox]

Yeah I’ve heard that newer versions of Meditech are somewhat more useful.

Back when I was stuck using it, it had that 1980s style black screen command prompt and wasn’t able to do all sorts of things that other EMRs had been doing for years. Truly “Meditrash”. Cheap ass hospitals like it because it’s cheap. But it’s ****.

Yeah, my buddy out in LA has the NewestVersion of Meditech and says that it's REALLY slick.

 

[VA Hopeful Dr]

I got sued a few years back because he scribe didn't document properly and I didn't catch it

 

[PB2464]

Hey ya'll, new attending here. Looking for some advice on how to best maximize scribes.

Our group uses scribes and trains their own scribes and they def are pretty good at charting etc and capturing the key components of billing for the new coding/billing guidelines. I'm struggling with the workflow of using scribes. In residency - I would see a patient, chart a brief MDM and as labs came in and imaging came in, I would document them and "run my list" from top to bottom to make sure I wasn't missing anything. Our scribes will ask for imaging/ekg/lab interpretations while I'm doing other things (maybe chart reviewing another patient, etc) and it causes me to pivot and lose track of what I'm doing (thanks ADHD). In my first few shifts, I've found that by doing this, I end up not having a great grasp on the nuances of my patients and I feel like I'm running around like a chicken with its head chopped off and it's affecting my efficiency/makes me afraid that I will miss something.

Any useful tips on how to maximize scribes? I was going to trial telling the scribes that I will "run my list" every half hour or so to catch up on all those labs etc that way I'm also reviewing everything but I'm not sure if that'll be effective. Thanks!

Waste of time and money unless they can help documenting MDM as well as discharging etc.
You will still go thru charts and find mistakes making you lose the whole "efficiency" of having a scribe.
Dragon dictation is all you need.

 

[JacobMcCandles]

Click Dispo.
say: "Bye Felicia!" (yes, I really set that up)

There. I'm done.

I always wonder about stuff like that and lawsuits. I’d imagine it would be discoverable and would 100% be used to paint you in a bad light regardless of the merits of the case.

 

[HemorrhagicShock]

Click HPI.
say: "ZIP COPD exacerbation"
Click PE.
say: "ZIP COPD exam"
Click MDM.
say: "ZIP COPD ADMIT".
Click Dispo.
say: "Bye Felicia!" (yes, I really set that up)

I've been an attending for years now, have worked in Epic and Cerner environments (both with Dragon), am the highest biller in our group, yet I still don't know how docs can set up their documentation to be THIS efficient.

Is that truly all you do for a COPD chart? How do you delineate nuances? Why did you not work this patient up for a PE? Why was this COPD admitted vs discharged? What if they have amputated legs, chronic L-sided deficits from a stroke, and a peritoneal dialysis catheter? How does your template approach address/assess/consider any of those curveballs if you work with a stupidly sick, chronically ill, and underinsured population?

I am asking these questions genuinely because I would like to be able to do a COPD chart in 30 seconds, but I find myself taking about 4-5 minutes in a complex patient Cerner/Epic/Dragon environment where I also have to make multiple calls and document them.

 

[RustedFox]

I've been an attending for years now, have worked in Epic and Cerner environments (both with Dragon), am the highest biller in our group, yet I still don't know how docs can set up their documentation to be THIS efficient.

Great questions, bro. I'm not mocking you, I'm agreeing.

Is that truly all you do for a COPD chart?

For a totally normal, run of the mill COPD admit, yes.

How do you delineate nuances?

The autotext program allows you to use closed brackets in your autotext as "fields to tab thru". I can either add data or delete them with the microphone.

Why did you not work this patient up for a PE?

Because they didn't have one, obviously.

Why was this COPD admitted vs discharged?

Admitted. Discharged COPDers have a different script.

What if they have amputated legs, chronic L-sided deficits from a stroke, and a peritoneal dialysis catheter?

Then add that to your physical exam fields. I use the phrase: "BATTER UP!" and it spits out a "normal exam" that I can then edit myself. Each section of the physical exam is * well-spaced out * in my zip phrase, so I can just highlight each section and replace it if necessary. For example, I can just double-click on "HEART" to highlight the whole section, and say: "ZIP, REGULAR TACHY" and correct that. Chronic, permanently present neuro changes? "ZIP, BASELINE NEURO" (patient awake/alert and at neurologic baseline with prior defects as per inpatient records).

How does your template approach address/assess/consider any of those curveballs if you work with a stupidly sick, chronically ill, and underinsured population?

That sounds like IM's job (only kidding, bro). This workflow is for your "boring, straightforward COPD exacerbation". If I see enough of a variant, I add a ZIP-phrase to the dictionary and give it a catchy name.

Common "bridging phrases" for MDM are named things like: "ZIP RESPOND", "ZIP RESOLVED", "ZIP POP", "POP TOP", "ZIPPITY BOP", and "ZIP VAN HALEN" (because I like Van Halen). Do I remember what each one contains? Yes. Am I a loser? Probably, yeah. Am I a loser that leaves every shift with an empty document tracker? Yes.

I am asking these questions genuinely because I would like to be able to do a COPD chart in 30 seconds, but I find myself taking about 4-5 minutes in a complex patient Cerner/Epic/Dragon environment where I also have to make multiple calls and document them.

There's a couple of strategies I use to maximize this. I'm not exaggerating when I say I have about 600+ "ZIP-phrases" set up and saved. I think the most important strategy is: * I only ever use the free text fields and a general medical chart template. * The less you lock yourself into, the better.

80 year old male falls at 5 am getting up to piss and bonks his head?

HPI:

"ZIP Senior Sunrise Special"
"ZIP Controlled Fall"
"ZIP no other injury"
"ZIP UP"

PE:

"BATTER UP!"
(double click to highlight head/neck section).
"ZIP HEAD BONK"
(Arrow key to brackets)
"Small contusion to occiput".

MDM:

"ZIP SAFE-1"
"ZIP Discussion"
"ZIP DC to ECF"
"ZIP OUT"

 

[RustedFox]

I always wonder about stuff like that and lawsuits. I’d imagine it would be discoverable and would 100% be used to paint you in a bad light regardless of the merits of the case.

They got better things to do than sniff that out.

 

[Siggy]

I am asking these questions genuinely because I would like to be able to do a COPD chart in 30 seconds, but I find myself taking about 4-5 minutes in a complex patient Cerner/Epic/Dragon environment where I also have to make multiple calls and document them.

Anything with in [brackets] can be jumped to using the command "Next field."

The command "accept default" will delete the brackets and leave anything inside the brackets alone.

So I have a template normal physical exam, but I can jump easily though it and then delete the brackets when I'm ready to move on. Similarly my NP/critical care attestation has brackets for a place for me to put additional info, brackets in an area to put diagnoses, brackets for NP time, brackets for my time, and brackets for total time.

So documenting the attestation becomes "Next field, "synopsis," next field "diagnoses," next field "NP time" next field "my time" next field "total time".

 

[Tenk]

We used to have the same three scribes. It was awesome. They knew exactly what I did and didn’t want in a chart. They could even write my MDM. It definitely made my job easier.

Then they all went to medical school and we got random replacements who were terrible. We all decided to stop using them.

I think if you have the same scribe(s) all the time and they can learn your style, it’s worth having them. If it’s always a new face and you spend half the shift telling them what to include or not include, it’s just annoying and not worth it.

 

[BoardingDoc]

I just looked at my dot phrase program. I apparently have 237 different dot phrases across my exam, MDM, discharge, procedures etc.

Agree with @RustedFox on this one. With enough prep, you can do a grand total of maybe 1-2 minutes of charting including their chart and discharge papers with enough generic macros and a few usefully specific macros.

I'm currently 8 hours into my shift. I've primaried 26 patients so far. My charts are signed on 23 of them. The other 3 will be done when I finalize their dispos.

 

[TooMuchResearch]

I just looked at my dot phrase program. I apparently have 237 different dot phrases across my exam, MDM, discharge, procedures etc.

Agree with @RustedFox on this one. With enough prep, you can do a grand total of maybe 1-2 minutes of charting including their chart and discharge papers with enough generic macros and a few usefully specific macros.

I'm currently 8 hours into my shift. I've primaried 26 patients so far. My charts are signed on 23 of them. The other 3 will be done when I finalize their dispos.

That's a lot of pph

 

[BoardingDoc]

That's a lot of pph

Pure productivity group. I don't have to move that fast if I don't want to, but I make a lot of money if I do, so I usually do if I can.

 

[RustedFox]

I'm in a CMG at various sites with various models.
Right now (and thru the end of the year), I'm at a FSER with a flat 255/hour rate.
The work is light, but I need a break.
I work only nightshifts, and only 5-6 shifts/month (I have a side-gig that is becoming my main gig).
I've really refined my ZIP-phrases with the downtime.

 

[thegenius]

I've never understood the appeal of scribes if you've got dragon. I really also don't need or want some kid following me around into each patient room and then sitting next to me just staring at me if I'm not talking to them as I then either have this socially bizarre situation, or I'm pushed to make small talk with them...which wastes time ... Which defeats the entire purpose of having a scribe in the first place.

Good scribes I can see an extra 3-5 patients on a standard 9 hr shift.

Cerner sucks balls it's all clicking, and it's slow. I would rather have the scribe click around all the buttons than me. There are innumerable number of dropdowns and clicking and it's simply kludgy.

I personally cannot dictate a single sentence without correcting it. So I would suck at dragon.

I do understand that scribes are not for everyone. If it's really busy I want a scribe.

Plus the good ones do cool things like "Yea the patient you are going to see was discharged 4 days ago for pneumonia" when all the board says is "John Doe 74 Male - Weakness".

OP, just talk to your scribes and work with them. They will adapt. we have like 40+ and i'm lucky that I only routinely work with like no more than 4 of them, and we flow quite well.

 

[thegenius]

They are not helpful other than writing an incorrect history, interrupting me, and screwing up the time-stamped information they are supposed to capture.
I do not review their HPI because that would nullify any possible time savings they offer.
I have attempted to stop using them and was told I am required to use them.
I send them home early whenever feasible.
I would happily stop using them tomorrow.

For real? that's f'ed up. How can you force a doctor to use a scribe? If you don't want to use them I would just tell them to sit in the corner, or follow you around, but don't chart anything. Or don't use what they chart.

 

[thegenius]

Great questions, bro. I'm not mocking you, I'm agreeing.



For a totally normal, run of the mill COPD admit, yes.



The autotext program allows you to use closed brackets in your autotext as "fields to tab thru". I can either add data or delete them with the microphone.



Because they didn't have one, obviously.



Admitted. Discharged COPDers have a different script.



Then add that to your physical exam fields. I use the phrase: "BATTER UP!" and it spits out a "normal exam" that I can then edit myself. Each section of the physical exam is * well-spaced out * in my zip phrase, so I can just highlight each section and replace it if necessary. For example, I can just double-click on "HEART" to highlight the whole section, and say: "ZIP, REGULAR TACHY" and correct that. Chronic, permanently present neuro changes? "ZIP, BASELINE NEURO" (patient awake/alert and at neurologic baseline with prior defects as per inpatient records).



That sounds like IM's job (only kidding, bro). This workflow is for your "boring, straightforward COPD exacerbation". If I see enough of a variant, I add a ZIP-phrase to the dictionary and give it a catchy name.

Common "bridging phrases" for MDM are named things like: "ZIP RESPOND", "ZIP RESOLVED", "ZIP POP", "POP TOP", "ZIPPITY BOP", and "ZIP VAN HALEN" (because I like Van Halen). Do I remember what each one contains? Yes. Am I a loser? Probably, yeah. Am I a loser that leaves every shift with an empty document tracker? Yes.



There's a couple of strategies I use to maximize this. I'm not exaggerating when I say I have about 600+ "ZIP-phrases" set up and saved. I think the most important strategy is: * I only ever use the free text fields and a general medical chart template. * The less you lock yourself into, the better.

80 year old male falls at 5 am getting up to piss and bonks his head?

HPI:

"ZIP Senior Sunrise Special"
"ZIP Controlled Fall"
"ZIP no other injury"
"ZIP UP"

PE:

"BATTER UP!"
(double click to highlight head/neck section).
"ZIP HEAD BONK"
(Arrow key to brackets)
"Small contusion to occiput".

MDM:

"ZIP SAFE-1"
"ZIP Discussion"
"ZIP DC to ECF"
"ZIP OUT"

What the F is ZIP? WHY ARE YOU SAYING ZIP?

ZIP BATTER UP! LOL
ZIP DINGUS MCGEE PSYCH
ZIP UP AND ZIP OUT

 

[thegenius]

I work at a Kaiser (doesn't have scribes, uses Epic)
and non Kaiser site (has scribes, uses Cerner)

I'm just as fast at Kaiser, if not faster. but I attribute that to the fact that my charts are much simpler at Kaiser. They don't really enforce things like writing CC time, putting all this extra nonsense in the chart for billing purposes. It's quite nice actually. Plus Epic is 10x better than stupid dumb Cerner PowerChart.

 

[Janders]

My only meaningful scribe use was at a moonlighting gig using epic and dragon where we basically ran a pod that was mostly fast track to low:mod acuity, some CT bellies and occasional PE work ups being about as sick as the got. Also covered a fair amount of the psych. Rather high English as second language population

1/3 of the scribes were good, probably added 0.5pph to my speed. They were smart. Experienced. Thought ahead. Pulled old EKGs, discharge summaries and gave them to me. Got interpreters up before we went in the room. Acted like unit coordinators as far as calling consults and admits went. Frankly their actual scribing was less important that all the gopher stuff they did, but it let me sit and talk to the patients a couple extra minutes while they typed the HPI.

I did not have them do my exams, much easier to template : add pertinent myself.

I rarely had them do much to the MDM aside from adding notes that we used interpreter or consulted xyz. They were smart enough yo make non-incriminating HPIs.

I would pay $20/hr to have one of these with me.

1/3 of the scribes were fine but were under motivated and couldn’t editorialize an HPI so just wrote stream of consciousness of whatever the patient said. They could be directed. But they didn’t speed me up at all. I wouldn’t have paid a penny for them. I generally preferred not to have them, as I don’t like fixing every hpi they type.

1/3 of scribes were terrible and actively slowed me. Blatantly wrong hpi. Couldn’t stay on task. Would leave 10 charts open (so I couldn’t get into them to do my part) even when I asked them not to. I would do everything possible to pay them to make coffee runs and suggest they take a 2-3hr (paid) lunch breaks… As a treat to myself.

 

[RustedFox]

What the F is ZIP? WHY ARE YOU SAYING ZIP?

ZIP BATTER UP! LOL
ZIP DINGUS MCGEE PSYCH
ZIP UP AND ZIP OUT

it cues the microphone that the next word(s) will be a command, and are not to be typed out.

 

[BoardingDoc]

I'm in a CMG at various sites with various models.
Right now (and thru the end of the year), I'm at a FSER with a flat 255/hour rate.
The work is light, but I need a break.
I work only nightshifts, and only 5-6 shifts/month (I have a side-gig that is becoming my main gig).
I've really refined my ZIP-phrases with the downtime.

You getting close to give the scoop on your side gig? Very curious. I know you've been working at it for a while now but have wanted to hold off till things were on firmer footing.

 

[HemorrhagicShock]

HPI:

"ZIP Senior Sunrise Special"
"ZIP Controlled Fall"
"ZIP no other injury"
"ZIP UP"

PE:

"BATTER UP!"
(double click to highlight head/neck section).
"ZIP HEAD BONK"
(Arrow key to brackets)
"Small contusion to occiput".

MDM:

"ZIP SAFE-1"
"ZIP Discussion"
"ZIP DC to ECF"
"ZIP OUT"

Incredibly helpful post bro, I appreciate it FULLY.

Indeed, I've had people try to teach me this approach (effectively, just more quantized/mini-templates to build in individualization for the case with strategic placement of variable brackets/whatever your EMR uses and then forwarding/tabbing/F-whatevering through them quickly).

The problem I've had with this approach is that it takes me about the same amount of time (4-5 minutes) to complete the aforementioned complex COPD chart using that approach or just my normal approach.

A likely component of it is that I'm probably too pedantic and superfluous with the information I THINK I need to offset medicolegal liability, capture all the charges, actually have a clinically usable note, and not have the patient complain about me when they read the note in their portal.

 

[HemorrhagicShock]

Anything with in [brackets] can be jumped to using the command "Next field."

The command "accept default" will delete the brackets and leave anything inside the brackets alone.

So I have a template normal physical exam, but I can jump easily though it and then delete the brackets when I'm ready to move on. Similarly my NP/critical care attestation has brackets for a place for me to put additional info, brackets in an area to put diagnoses, brackets for NP time, brackets for my time, and brackets for total time.

So documenting the attestation becomes "Next field, "synopsis," next field "diagnoses," next field "NP time" next field "my time" next field "total time".

This is almost exactly what I do, and yet I still have a 4-5 minute note time (average) per patient.

Dental pain? 30-second chart

ESI 3 walking chest pain? 30-second chart

34 year old easy abdominal pain? 30-second chart

34-year-old ESRD patient complaining of abdominal pain, chest pain, AND dental pain, all of which made their way into the triage RN's note, who knows none of their meds, gets seen routinely in the nearby 3 EDs whose EMRs we can't access readily, and inevitably has a variety of issues that are near surmountable anytime you try to admit him? 4-5 minute chart if I'm lucky.

Unfortunately, these days, it seems that 90% of my patients are the last one in my list above, not the first three.

 

[comp1]

I can type so much faster than I can talk, particularly to another person. I've never understood the benefit of scribes at all, but then I'm a weird person who prefers charting to patient interactions anyways. Patient stories are chaos. Charting is order.

 

[TooMuchResearch]

For real? that's f'ed up. How can you force a doctor to use a scribe? If you don't want to use them I would just tell them to sit in the corner, or follow you around, but don't chart anything. Or don't use what they chart.

Oh I did all that and was then told to use them.

 

[TooMuchResearch]

You getting close to give the scoop on your side gig? Very curious. I know you've been working at it for a while now but have wanted to hold off till things were on firmer footing.

I would also like to know about this new endeavor...

 

[RustedFox]

You getting close to give the scoop on your side gig? Very curious. I know you've been working at it for a while now but have wanted to hold off till things were on firmer footing.

January.

 

[thegenius]

I don't know how any chart can be 30 seconds if we need to import "reading past notes" or "read these labs on this date" and other things we have to do to justify our billing.

 

[BoardingDoc]

I don't know how any chart can be 30 seconds if we need to import "reading past notes" or "read these labs on this date" and other things we have to do to justify our billing.

Why are you doing those things?
Reading prior notes just gets you one point in the same column as ordering a test does. If you've ordered 3 tests and interpreted an x-ray, you're already a lvl 5 in that column. If you admit the patient, you're a lvl 5 in the 3rd column as well and you're done. If you're discharging them, just write an Rx for anything and now that column is a lvl 4 which is a reasonable chart lvl for a DC. Or click the button that says "I considered admitting them but didn't because xxx, e.g. low heart score and negative trops" Now you're back to a lvl 5 in that column and overall as well. No record review or old lab review required.

TL;DR: reviewing old records/labs is literally only useful for the patient whom you are not ordering any tests on.

 

[VA Hopeful Dr]

it cues the microphone that the next word(s) will be a command, and are not to be typed out.

I'm fairly new to dragon and had no idea this was a thing. Thank you!