SDN Article: Scribing Basics for Premeds: From Observation to Documentation

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Kyle Magatelli

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For pre-medical students, gaining clinical hours and direct exposure to the work of physicians is a necessary step in building a competitive application. Likewise, aspiring physician assistants (PAs) also need hours of clinical experience. Medical scribing is a great way for students to gain exposure to medicine and actively engage in the learning process. Admissions committees value scribing as an excellent method to accumulate hundreds of hours of healthcare experience, shadow physicians, and understand physicians’ thought processes during patient encounters. This article will provide the premed scribing basics and detail how this experience can enhance your application as a medical or PA school candidate. Our focus here is on scribing within the context of healthcare delivery in the United States.

What is a Scribe?

A member of the healthcare delivery team, a scribe records the physician’s notes that become part of a patient’s medical record. Scribes play a vital role in reducing physicians’ administrative burdens, allowing them to dedicate more time to their patients. According to a study conducted in 2017, scribes can significantly increase physician satisfaction and charting efficiency with no reduction in patient satisfaction. Hospital systems have increasingly begun to employ scribes, recognizing their positive impact on physicians and clinic productivity.

What Skills Are Needed as a Scribe?

The skills needed for scribing are typically taught during the training process. Unlike typical shadowing opportunities, scribes delve into the complex world of electronic health records (EHR).

According to the Joint Commission, which accredits healthcare organizations such as hospitals, scribes should be trained in the following:

  • Medical terminology
  • Health Insurance Portability and Accountability Act of 1996 (HIPAA)
  • Billing, coding, and reimbursement
  • Electronic medical records (EMR)
  • Computerized order entry

Beyond the healthcare specifics, scribes benefit from fast typing skills and a strong memory, as information flows rapidly during patient encounters. Training requirements vary based on the healthcare environment and organization. For example, training might involve primarily shadowing and on-the-job learning in a free clinic, whereas companies contracted by health systems often provide their own training curriculum.

A Day in the Life of a Scribe

While specific practices and starting times may differ, scribes generally follow a similar routine in terms of responsibilities. Upon arrival, a scribe logs into their Electronic Health Record (EHR) software and, in a typical clinic, reviews the physician’s schedule. In urgent care or emergency departments, where patient schedules are less predictable, scribes create encounter notes as the physician attends to each new patient. Scribes typically meet with the physician to discuss the day’s schedule and patient turnover in the ER or other pertinent information.

As patient encounters commence, scribes accompany the physician, diligently documenting all necessary information to create a comprehensive note. Scribes use the SOAP format, which includes recording the patient’s chief complaint, symptoms, duration, past medical history, vital signs, examination findings, diagnosis, and treatment plan. These details are entered into the EHR, including progress notes, test orders, and prescriptions. The accuracy and thoroughness of these notes are vital for continuity of care, enabling physicians to access the prior information, test results, personal/family medical histories, and medication histories necessary for effective treatment.

What is SOAP?​

The SOAP medical history format is a widely used method for documenting patient information and clinical notes. It provides a structured and organized way to document patient information, making it easier for healthcare providers to communicate and collaborate on patient care. Additionally, it helps ensure that all relevant aspects of the patient’s condition are considered in the assessment and treatment planning.

The SOAP acronym stands for:

1. Subjective: This section includes the patient’s subjective complaints and symptoms, as reported by the patient. It includes details about the patient’s chief complaint, history of present illness (HPI), past medical history (PMH), family history (FH), social history (SH), and any other relevant information provided by the patient. Basically, it’s the patient’s story in their own words.

2. Objective: The objective section contains information that is observable and measurable. It includes findings from the physical examination, laboratory test results, diagnostic images, and any other objective data that the healthcare provider has collected during the patient encounter. This section should be factual and not include interpretations or diagnoses.

3. Assessment: In the assessment section, the healthcare provider summarizes their professional assessment or diagnosis based on the subjective and objective information. This is where the provider states their working diagnosis, differential diagnosis (if applicable), and any other relevant clinical impressions.

4. Plan: The plan section outlines the course of action for the patient’s care. It includes the treatment plan, medications prescribed, diagnostic tests ordered, referrals to specialists, patient education, and follow-up instructions. It details what steps will be taken to address the patient’s condition.

With the fast-paced nature of healthcare settings, scribes may not always complete each note before the next encounter begins. Effective time management and organization skills are essential, as they might need to finalize previous notes after an encounter concludes.

Benefits of Being a Scribe

The primary benefit of scribing is gaining clinical experience. Pre-med students actively participate in healthcare delivery, encountering a variety of cases while closely observing and assisting the physicians they work with. This exposure, combined with acquiring medical terminology, charting skills, HIPAA knowledge, and familiarity with the ICD system, ensures that prospective medical school students are well-informed about the role of attending physicians.

Scribing also fosters the development of written and oral communication skills. Medical notes must be clear, concise, and direct. Developing these communication skills as a scribe provides a valuable advantage when embarking on medical training, where the curriculum proceeds at a demanding pace.

Moreover, scribing offers an intimate look at the functioning of the United States healthcare system. Scribes witness the intricate processes involved in a physician’s work, including the necessity of meeting insurance billing requirements. Diagnostic and procedure codes within notes determine the amount billed to a patient’s insurance. These codes follow the ICD-10 system, a globally used diagnostic system representing diseases and conditions. While mastering these codes may seem daunting, it’s an essential skill for aspiring physicians.

Finding Scribing Opportunities

Scribing opportunities are available nationwide. SDN’s Activity Finder provides a search function to allow you to research open positions in your area.

Is Scribing the Right Choice for You?

Scribing is an excellent opportunity for pre-med students to gain direct, hands-on experience and gain a comprehensive understanding of the realities of medicine. It comes with a steep learning curve, long hours spent on your feet, potential for night and holiday shifts (depending on the practice setting), encounters with challenging patients, and unforeseen extended shifts. However, if you want to become a physician, these challenges should not deter you. Besides, if you need to get clinical experience, you might as well choose an activity with an option for getting paid to do it!

The post Scribing Basics for Premeds: From Observation to Documentation appeared first on Student Doctor Network.

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