To those who use scribes: How to be better? How to make this experience more useful?

[Hospitalized]

To the attending physicians who use scribes, what are some qualities you appreciate in a scribe?

I ask because I'm at the 9-month mark as a scribe. At this point, I feel that I have the basics of charting down. I can write a good HPI and have received complements from physicians. However, I know that physicians still occasionally add material to my HPI at the conclusion of the shift; I've seen it when they are reviewing my charts. I still try ask for clarification occasionally on those weird histories.

Now I'm just trying to figure out other things to improve: effective wording, communication when I'm unclear on the differential or exam (why did you do this certain exam technique?), and updating the physician of labs/imaging right when they come back. What else can a scribe do to help out or improve their charting?

I'm going to be doing this job for another 2 years, so I want to try and get the most out of it, both for myself and for the efficiency of the physicians.

Any input is helpful. Thanks!

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[EctopicFetus]

Ill be brief. I ran my scribe program at my job. Often times when people add stuff it is because something important was missing. Not necessarily something you would have been expected to know. I would keep asking as I think this is useful for your own education and will make your charts better. We have a vry strict training program so the ones who make it through typically have the ins and outs of charting.

Also, depending on the doc ask questions when appropriate.

 

[DoctorMedic]

One thing that is nice is to ask, "do you have anything in particular you like in your charts" w a new attending. Also most of the time we truly only ask pertinent questions, no's are just as important as yes's to me.

 

[link2swim06]

I don't use a scribe but there are certain red flag symptoms I like to document the absence of in my charts. Honestly, to know these for each condition you would have to go to med school yourself but they are important to document from a medical-legal standpoint.

I guess with experience you will start figure out some of these (i.e. all my back pain charts say no urinary incontinence, no saddle anesthesia, denies IV drug abuse, no recent back injections, no fever, no weight loss; this helps me r/o a lot of scary stuff that wouldn't be apparent to someone without med school training).

 

[BAM!]

the most useful scribes are the ones who do more than just chart. answering phones, looking up insurance, recent admissions, paging consultants, etc.

There will always be things that are written differently. You're not expected to write everything perfectly for every doctor. This is understood because you haven't gone through med school and residency.

 

[KinesiologyNerd]

the most useful scribes are the ones who do more than just chart. answering phones, looking up insurance, recent admissions, paging consultants, etc.

There will always be things that are written differently. You're not expected to write everything perfectly for every doctor. This is understood because you haven't gone through med school and residency.

ehhhh depending where you are you absolutely can't do most of those things*. I almost got fired for asking a patient which Dr. Patel was their PCP. I was the old records magician though.

* except for night shifts at the smaller community ED. Go crazy!

 

[docdragon]

If you're not sure whether your doctor is telling you something to educate you or to put it in the chart, ask. If you're really not sure and the doctor is talking about the specific patient, put it in the chart. If you fail to document a red flag item that the doctor specifically told you as a pertinent positive or negative... or even something basic like the time of a toxic ingestion... You will certainly learn more of these as you get more experience, but you should still pay attention. I find out what other attendings don't document by watching what my scribes fail to transcribe, and there are definitely red flag items that get blown off. Please spell and punctuate accurately. Gest bikawse i werked all knight dont meen i ddont notish.

 

[RugbyTX]

1 year scribe here. Being observant helps the physicians a lot. 4 eyes are better than 2 and most appreciate it if you mention things to them and aren't an idiot. An example would be the other day when the 80ish lady presented with intermittent morning dizziness onset 4 months with multiple physician f/u. Well I happened to be charting on the side of the room next to her medications and noticed the boldy written, giant words informing her to take her Carvedilol with food or it may cause dizziness. Informed the doc since that med wasn't in the system, who asked her at recheck if she ate breakfast (since she previously stated she took her meds in the morning), and she didn't. Problem solved. A similar example would be me seeing the Norco bottle in a ladies purse (on accident of course, it was sitting wide open) and letting the doc know since she was c/o neck pain after an MVC, stating she hadn't seen a doctor in years, and was requesting pain meds constantly.

 

[Doghead]

If you've mastered the expectations as a scribe, from there on out it's your own curiosity that will add to your skill set. Remembering important symptoms of an obscure pathology you remembered seeing once. It's all experience. There's no way you'll ever avoid a physician adjusting your chart every once in a while. Unless you have the experience they do, there's going to be things here and there you just haven't learned. Even then, physicians reviewing other physicians charts would STILL alter and add things, because everyone likes it different.

 

[Tiger26]

Agree with the above--the things that would be really helpful for a scribe to do are basically notifying me of labs/images back and doing some secretarial work.

Instead, I'm generally anti-scribe because all the ones I've worked with just put a sloppy note in the chart and then I spend all my time having to edit them at the end of my shift. I'm kind of a documentation snob so scribes negatively impact my efficiency.