Tips on being a good ER Scribe?

[Evisju7]

I've heard from ER doctors about the scribes that make a lot of mistakes and how the doc must go back and correct the charts to the point of excess. I don't want this to be me.

Currently, I'm training for a scribing job and I was hoping that someone would give me tips on how to do a better job. If done correctly, scribes could be a helpful tool that allows a physician to spend more time understanding a patient and getting a detailed story of their issue. However, this requires them to trust that their scribe is documenting everything accurately so that they can have focused attention on their work.

This is VERY important to me, that I be a trusted aid rather than a burden. How can I ensure I do my job well? Does anyone have tips?

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[mehc012]

The Basics:
Watch what they look at during the exam. If they don't check it, don't mark it down.
Conversely, if they spend more time than usual on one system (an extensive neuro exam, for example), document the CRAP out of that system.
Listen to their wording. If they phrase an exam finding or a question in a particular way, use that phrasing. There is particular meaning to some phrases, such as "thunderclap onset" or "worst headache of my life"
- Once you've learned some of these key phrases, look for ways the doc is trawling for that info without explicitly saying it...for example "when was the last time you had a headache this severe?" is often used not only for timeline info, but also because if the patient supplies an example, you've automatically ruled out "worst headache of my life" without setting the patient up to over-dramatize it.

Write down times for everything - calls, procedures, first time you see the patient, etc.

Learn the doc's normal discharge instructions and have them ready to go before they ask. If almost every abdominal pain discharge gets the same instructions, put those in as soon as you get an abdominal pain patient...odds are that the only time they won't need it is if they're being admitted, and then they won't print anyway.

Extras:
Listen carefully if the doc explains their plan to the patient. If, while you're in the room, the doc tells someone that they will be getting an ultrasound and basic labs, and then you notice that an ultrasound was never ordered, it is perfectly reasonable to ask them "so you told Mrs. X that we would be getting an ultrasound, are we still planning to do that?" or just "so, what are we looking for on Mrs. X's ultrasound" if they are touchy and you need to avoid sounding like you're pointing out an error. Paying attention like this can save hours if it turns out that the US was ordered, but not the labs, or vice versa, but the lapse gets overlooked until they're ready for discharge after getting half of their stuff. You'll also (occasionally) see them enter orders backwards...the CT on Mrs X and the US on Mr Y, and catching them early saves time and money.

Pay close attention to details such as hysterectomies, Hx of kidney disease, etc. A lot of studies require other tests to precede them - women of childbearing age, for example, almost always get a pregnancy test before a CT exam. If you pay close attention when filling out the SHx portion of the chart, you can sometimes point out 'hey, Mrs Y had a hysterectomy' when the nurse or CT tech tells the doc they won't go until the blood test comes in. Same with contrast studies and kidney failure...it's just easier to know it up front.

If your doc prints a script, go grab it for them without being asked. Most of the time, you can hand it to them before they remember they wanted to go get it from the printer.

Most of it, though, you just have to learn on the job by eventually figuring out each individual doc's preferences and style. It's kind of a crappy trial-and-error process, but by the end it can feel phenomenal.

 

[Hospitalized]

First and foremost, come to terms with yourself that you do not have 8+ years of medical training. You do not have the knowledge to understand every case to the extent a physician does, so they simply cannot expect you to be able to fill in every detail for the chart that they are implying when they evaluate the patient.

For yourself, KEEP A LIST OF PATIENTS. I can't emphasize this enough. It keeps everything straight. Some doctors request it, other don't. You should ALWAYS have one.

You should try to document everything that occurs on your shift. You want to shoot for a 100%. But, let's be real. There's absolutely no way you can get 100% of all information on every one of your shifts. Doctor's forget to put orders in, forget to consult a specialist on a patient, and even forget to ask pertinent questions at times. We are humans, we're not perfect. I put myself around 96-100% on a regular basis, and physician's I work with treat me very well and tell me my charts are good. There are times when I've forgotten very pertinent information. It happens. Like I said, we're not perfect. When I'm in doubt, I always just ask the physician, "is there anything else specific you would like in this chart before I'm done with it?" before discharge/admit. This covers both you and the physician. Often times, they say something that's probably already in there. This lets you know that you are doing your job correctly, as you've gotten the most pertinent information in the chart (the thing that first came to mind for them).

You will begin to catch on to presentations that occur over and over, and things that physician's tend to look for, like meningeal signs in a headache, peritoneal signs in abdominal pain, wheezes/rhonchi/rales in coughers/SOB, and so on. This stuff gets routine and you will have go-to phrases you can put in your MDM. I'm to the point now where I can do a level 5 chart in <5 minutes after the assessment. When I was first on my own, I wouldn't even be able to comprehend what I do with charts now and the efficiency I've learned.

At the end of the day, you are creating a chart that 95% of the time has minimal significance, ever. The most important charts are when patients get admitted, have an extensive medical/ER visit history, or are hostile towards the doctor (as that could be the one that goes to court). Doctor's will dictate to you more on these charts, naturally. Or at least I hope they do. And they probably go back and edit them after shifts more frequently.

Your trainers and program will stress the crap out of you saying how important your job is. Ultimately, you are just making the physician's life easier and doing their dirty work. Come to terms with that, master it, and then start learning medicine. It's a very fortunate position to be in.

 

[Dr Granger]

I've been working as a scribe for almost 2 years, and the hardest part is just getting the hang of things! For me, after the first month is when I started to get really "good"

Also, I've learned every ER has a different set-up. For example, we have PAs that help the Docs, and they write the orders and do a full physical exam.

Congrats on the Job! I hope you love it as much as I do 🙂

 

[Ace Khalifa]

I agree with everything @mehc012 and @Hospitalized said. I'll add in that you should pay attention to everything that goes on and of course, timestamp everything. Sometimes you won't know what to type for certain HPI's, and it's perfectly okay to ask your doc to dictate to you the pertinent details. Finally, always be professional and do whatever you can to make your physician's job easier. It will take a month or two to get used to things, but it's totally worth it. I wouldn't have remained as interested and dedicated to the field of medicine if I had done something else during my gap year. Good luck!

 

[Mayday_]

Everyone has posted great advice. A lot of that will be easier to really improve on after you get past the initial learning curve. I think a huge thing that has helped me gain the trust of a lot of providers is that the first one or two times I work with a provider, I ask them a lot of questions about their preferences on certain aspects of their charts. It may seem overboard at first, but it makes it so you don't go a whole shift making the same mistake on every chart. A lot of times if that happens the providers will get a bad first impression and that will stick for awhile. Strive to learn each doc's/midlevel's specific preferences and things will go much, much more smoothly.

 

[GaiusOctavius]

Writing a good HPI takes practice. Set them up the same way each time. Start with chief complaint, onset, and quality. Then move onto associated symptoms. Learn the common chief complaints and their associated symptoms; this will make it easier to know what's important.

For the ROS, you're basically just restating the symptoms that were in the HPI. For the physical, just listen to what the physician says and record it.

Master that stuff first, then you can work on anticipating physician needs by monitoring the progress of ancillary tests, etc.

 

[takeurmeds02]

I know you posted this last month. I hope it's still helpful!

- Google is your friend. Don't know a word? Sound it out and put it in google (make sure it makes sense in context lol)

- Remember that you're telling a story. It's more than just a set of symptoms; you're putting the symptoms in context to the patient and surrounding factors.

- Following the above bullet, try to be as succint and accurate as possible and don't take it personally if Docs completely amend your chart (although most don't). Like @Hospitalized said, you don't have 8+ years of med training. (I'm a closet-perfectionist and I still have issues with this point sometimes lol)

- If you find yourself in the situation where your charts are being frequently amended by multiple docs, ask how to improve your HPI composition. Who better to ask than your doctor? They'll respect that you are trying to learn and improve.

-In general, don't be afraid to ask questions even if they are repetitive (especially in the beginning). It's better that you record the correct information than to put down the wrong stuff and get chewed out for it. That being said, learn from each question so that you're not asking the exact same things that you were on day one.

Eventually, you'll switch over to autopilot and have more time to learn the medicine. I absolutely love scribing in my ER and I'm glad I have the opportunity to be right in the mix of everything. Good luck moving forward!

 

[Atmosphere123]

Don't kiss the doctor's ass.
Don't try to impress the doctor with your curiosity.
Only ask questions during times when the doctor is obviously not busy.
Don't ask a question if you can look up the answer on google.
Work quickly and silently.

 

[daffy duck]

I think the first thing you should focus on as a scribe who is just starting out is achieving a level of competence first and foremost. By this, I mean attempt to get the bare basics for your charts for all the patients you see. Once you get all the required information and cover your bases consistently, you can begin to excel and eventually tailor your service to fit the physician's particular style.

For me, the basics include spelling things correctly, using proper grammar, accurately documenting drug names and dosage information. It is also important to gather the required information from the physician as soon as possible as your are creating a chart in real time. From my experience, most physicians are very understanding that you are a newly trained scribe and that you will inevitably make mistakes. Everyone has a fear of failure and unfortunately an embarrassing situation is often the best lesson for inexperienced scribes. As long as you are eager to improve, most physicians will be understanding and willing to point out mistakes so that you can begin to improve.

As you get more experienced, you can begin to do things to distinguish yourself from your peers and, if you are lucky, earn a letter of recommendation from a physician you have worked with. These things include informing the physician when labs/imaging are returned, getting the appropriate forms (1013/outside hospital requisitions/blood consents), and getting blankets/food for patients.

To cut to the chase, in order to do your job well, focus on the basics and learn how to do what is required of you first.