TIps for Scribing?

[deleted1089232]

Hi,

I'm hoping to get any helpful tips/advice from experienced and former scribes or anyone knowledgeable on how to be a solid scribe? I will be starting my first day next week and am very anxious. I will be working in an ER and am afraid of working in extreme cases where there is a lot going on and feel like I'd be in the way of everyone and my hearing is not all the best if I'm being honest. I am a moderate typer. From the typing tests (which usually have simple words) I have a typing speed of about 72 wpm.

I would appreciate any tips!

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[reapplicant2021]

I just got accepted by SA so I don't have any first hand experience, but it seems that the aspect that slows you down is navigating the EMR interface. You'll also use a lot of abbreviations for longer medical terms, which will help.

 

[anhnen5]

Always ask questions and verify information! Never assume anything if you are not sure. Even if it seems annoying or the physician has to repeat themselves, the physicians will be a lot happier if the documentation is correct rather than wrong that could get them into legal trouble.

Also, this will come with experience, but really practice staying aware of your surrounding while you're working! Don't miss any re-evaluation notes or consults because you were so focused on documenting in the chart!

Also, think of a system to keep track of patients. Most likely you will see examples of tracking systems from your trainers. Everyone is different, so do what works for you. You will be juggling multiple patients at the same time so you have to keep track of what you need in the chart so that you can prompt the physician for what you need/to make sure a chart is finished.

Example of mine.
Room Number) Patient name #1
HPI, ROS, PMH, PE, MDM, DX, DISPO

Room Number ) Patient name #2
MDM, DX, DISPO

Then I just delete what is completed. So in this case Patient #1 still needs everything, most likely we have not seen the patient yet. Patient number 2 I finished the HPI, ROS, and PMH section. Still need the MDM, DX and DISPO section. So I will prompt the doctor for those if that pt is about to be discharged/admitted/transferred etc.

Good luck! Trainer here at SA so feel free to DM for any specific questions!

 

[sarcasmrules]

Be able to type 60 WPM with 100% accuracy.

 

[caterwaiter]

1. There's a gigantic learning curve to ED scribing. The longer you're there, the better you'll know how different providers like their charts done and how to get them done efficiently.

2. Developing a patient tracking system that works for you is crucial. We carry clipboards and take handwritten notes at my site, so we give every scribe a patient tracker chart with spaces for patient name, room, chief complaint, HPI/ROS/PE, labs, imaging, etc. Some modify it as they figure out what works better for them.

3. If your site doesn't already teach you, learn med terminology and a shorthand.

4. Trying to get all relevant info about a case while trying not to be in the way can get tough, particularly if you're in a trauma center. My general rules: you never need to be at bedside in a resuscitation/trauma situation unless specifically invited. If it's clear enough for you to stand somewhere and catch any history that EMS gives, that's useful info. When you're first starting out though, I'd lean towards hanging back and observing from a distance.
* all comes with the assumption that the doc you're scribing for can tell you about the patient later and you're not expected to be at bedside

 

[deleted1089232]

Be able to type 60 WPM with 100% accuracy.

Kind of scared of the 100% accuracy. Hoping that most terms could be found in the ROS. I can spell basic things but medical terminology can get tough!

 

[deleted1089232]

1. There's a gigantic learning curve to ED scribing. The longer you're there, the better you'll know how different providers like their charts done and how to get them done efficiently.

2. Developing a patient tracking system that works for you is crucial. We carry clipboards and take handwritten notes at my site, so we give every scribe a patient tracker chart with spaces for patient name, room, chief complaint, HPI/ROS/PE, labs, imaging, etc. Some modify it as they figure out what works better for them.

3. If your site doesn't already teach you, learn med terminology and a shorthand.

4. Trying to get all relevant info about a case while trying not to be in the way can get tough, particularly if you're in a trauma center. My general rules: you never need to be at bedside in a resuscitation/trauma situation unless specifically invited. If it's clear enough for you to stand somewhere and catch any history that EMS gives, that's useful info. When you're first starting out though, I'd lean towards hanging back and observing from a distance.
* all comes with the assumption that the doc you're scribing for can tell you about the patient later and you're not expected to be at bedside

Thank you this is very descriptive! It's comforting to know that we are not full-on expected to be able to hear everything in a trauma case and docs can inform us later -- hoping my location does this!

 

[deleted1089232]

Always ask questions and verify information! Never assume anything if you are not sure. Even if it seems annoying or the physician has to repeat themselves, the physicians will be a lot happier if the documentation is correct rather than wrong that could get them into legal trouble.

Also, this will come with experience, but really practice staying aware of your surrounding while you're working! Don't miss any re-evaluation notes or consults because you were so focused on documenting in the chart!

Also, think of a system to keep track of patients. Most likely you will see examples of tracking systems from your trainers. Everyone is different, so do what works for you. You will be juggling multiple patients at the same time so you have to keep track of what you need in the chart so that you can prompt the physician for what you need/to make sure a chart is finished.

Example of mine.
Room Number) Patient name #1
HPI, ROS, PMH, PE, MDM, DX, DISPO

Room Number ) Patient name #2
MDM, DX, DISPO

Then I just delete what is completed. So in this case Patient #1 still needs everything, most likely we have not seen the patient yet. Patient number 2 I finished the HPI, ROS, and PMH section. Still need the MDM, DX and DISPO section. So I will prompt the doctor for those if that pt is about to be discharged/admitted/transferred etc.

Good luck! Trainer here at SA so feel free to DM for any specific questions!

That's helpful to know! Tracking sounds like it would be a tough part fo the process. I think I'll handwrite to track as another poster suggested and dispose of it properly -- I guess we'll see how the location prefers things to be done. Thank you!

 

[deleted1025488]

Wait, are you not training? Like a 2-3 week period where you're with a lead scribe and you can just practice? Also an aside, ScribeU had like soooo much random information, in reality, you'll only use like 10% of it...depends on the provider though

 

[deleted1089232]

Wait, are you not training? Like a 2-3 week period where you're with a lead scribe and you can just practice? Also an aside, ScribeU had like soooo much random information, in reality, you'll only use like 10% of it...depends on the provider though

I honestly don't know. I would hope so but haven't really been told anything. That's good to know! I'm sure there will be a lot of new terms as well and having to get patient's medications may be tough since that's not covered to depth with spelling and it's use.