Article

Tips for effective scribing

Develop this unique skill set to help create a solid foundation for your career.

The practice manager who hired me as an ophthalmic scribe said she thought I was right for the position, in part, because of my previous work at Starbucks. The store had a busy drive-thru, requiring me to take orders while I prepared other orders away from my register. These tasks demonstrated auditory memory, a quality important for scribes. Shortly after I started scribing, a patient referred to the notes that were dictated as “a lot like ordering coffee!” I hadn’t thought of it that way, but I had to agree. Grande inferior subconj heme latte, anyone?

Scribing is a unique gig that requires good listening skills, quick comprehension, typing capabilities, and computer literacy, to name a few attributes. The skills gained in this position create a solid foundation for your career, whether your time as a scribe is long- or short-term.

Here are a few tips for becoming an effective scribe.

Understand expectations

Unlike many other jobs in the practice, scribes work at the doctor’s pace most of the time. There are only pockets of time, such as when the doctor and patient share small talk, in which you can set your own pace, perhaps catching up and organizing the medical record, times at which you still must pay attention. Become too focused on another task and you may only zone back in when you hear the doctor say, “Use this drop three times a day,” at which point you may wonder, “What drop?” Your focus and thoroughness determine how accurate your documentation will be and how much time you will save the doctor.

Prepare in advance of patients

Become familiar with the electronic medical record (EMR). This will help you know what’s under each ocular section. Click on terms, drop-down menus, etc. to learn what happens (under a test patient, please). Discover shortcuts and useful tools provided in the EMR. Be aware of all updates and new versions ahead of time by receiving information and updates from the EMR vendor.

Recognize common phrases. Identify language you frequently key in and turn those terms into “smart phrases,” or shortcuts that will auto-populate the record. The doctor might have created some phrases, but ask if you can add more. Assign keystrokes to each shortcut that are distinguishable from one another and therefore easy to recall. I recommend starting with what is being indicated. For example, “retinal consultation to be scheduled” will be more useful in the long term than “patient referred for retinal consultation.”

Execute while with the patient

Know why the patient is in the exam chair. Read the chief complaint and history documented by the technician. Verify why the patient has an appointment to determine the nature of the exam and primary diagnosis needed for billing purposes. Add important details to the “chief complaint” and “history” section of the record as the doctor asks further questions during the exam. Also, adjust “general health,” “medications,” and “allergy” sections if more information arises during the exam. (Note that your EMR system may be different and not have these specific headings. In those cases, identify the similar related field.)

Make the most of a minute. Get to know when there is likely to be free time to complete “assessment” and “plan” sections of the medical record. This pattern will be somewhat consistent depending on the type of visit. For example, during a dilated fundus exam, the doctor will use the indirect ophthalmoscope and you will have almost a solid minute (which is a lot of time when scribing) to fill in the blanks. Often, a lot can get done before the doctor examines the patient or before he gives you exam notes. Of note: The pace of dictation can vary from doctor to doctor and exam to exam for each doctor, but you can recognize consistency with the same doctor.

Note questions. Which eye is the doctor examining? Did he just give notes for “OD” and he is currently looking at “OS”? Sometimes you will look at the prior note and see the description was for OS and not OD. Other times, this could mean that it was not documented accurately at the last visit or that the doctor noted the wrong eye associated with the finding. It’s okay to ask a question if you need clarification, or something repeated, when there is a lull in the appointment. Part of your job is to eliminate chart note errors. If you are not sure if you have the correct diagnosis or all the necessary notes, ask for this information or leave a reminder in the chart for the doctor to complete it.

Scroll with it. If you cannot find the appropriate section right away, write down what you heard or free-text in the nearest open box — just remember to go back to find its correct place. It’s better to enter it somewhere sooner — and worry about spelling later.

Learn with the patient. The doctors are teaching you as they educate the patient. You have the benefit of hearing things more than once and are, therefore, more likely to remember them.

Listen for wrapping up cues. Once the doctor starts to finish up with the patient, be prepared to complete what you are doing (for now) so that you can help the doctor transition to the next patient. You can leave your seat and make yourself available to take over the patient’s needs. Keep a small notebook or Post-Its at hand, so that you can write down the record numbers of charts that you might have to complete later.

Review the chart. Should you experience “down time,” either during the exam or between patients, review the chart. Check for errors in spelling, create cohesiveness, and eliminate redundancies and irrelevant instructions that got carried forward from the prior exam. The same can be applied to the exam notes: Remove any diagnoses or descriptions that you know are resolved since last visit (e.g. if the patient had a chalazion four months ago, you can remove the diagnosis on this visit). Likewise, look for notes and descriptions from prior exams that can also be eliminated because they were very specific to that exam (e.g. “RUL everted; no foreign body seen” is not going to be done on this exam).

Follow-up

Get curious, stay curious. This will encourage you to do research and will help you to gain a closer understanding of what you are doing. Throughout the day, jot down terms with which you are unfamiliar and write down chart notes of patients with a new or unusual case and read the finalized chart later. Did the doctor change the diagnosis? Did he add to the “plan” section? Doing this will allow you to gain insight and learn moving forward. The more you learn about the concepts, conditions, and ocular anatomy, the more you will remember.

Listen

In today’s society, multi-tasking is deemed as an almost necessary skill in many professions and in attending to life’s responsibilities. Although listening can be seen as secondary in scribing, it is the top priority. If you are focusing on filling notes in a patient’s chart but the doctor begins giving the patient her instructions, you should pause typing and fully focus on those instructions. This way, you can capture the important instructions and be ready to clarify for the patient, should she need reiteration once the doctor has moved to the next patient.

Being fully focused eliminates errors and saves time. It could also be the difference between a nonfat caramel latte and a caramel latte. OP