The ABCs of scribing

Ophthalmic scribes can add substantial value to the practice. Here’s how.

Ophthalmic scribes can provide substantial value to the ophthalmology practice. By dictating exam findings to the scribe in the exam lane, the doctor can devote more time to thinking medically, rather than clerically, which can improve productivity. In addition, as the doctor does not have to both perform and document the exam, the patient can receive the physician’s undivided attention, which caan improve outcomes.

This article will present an overview of scribing activities, including tips for documentation, training and additional resources.

Provide proper documentation

Proper documentation in the medical record is critical in providing quality care and is required for providers to receive accurate and timely payment. Accurate records can allow any practitioner to take over the patient’s treatment simply by referring to their records. Documenting the doctor/patient conversation accurately is imperative in meeting legal and ethical obligations as well. It also can assist with insurance audits. For these reasons, the scribe must enter the record in a timely manner and never alter or back-date it in any way.

Per CMS Guidelines the documentation of each patient encounter should, according to CMS published literature, include:

  •  “Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results
  • Assessment, clinical impression, or diagnosis
  • Medical plan of care
  • Appropriate health risk factors
  • The patient’s progress, response to and changes in treatment, and revision of diagnosis”

Remember: if it is not documented, it has not been done.

Break down documentation

History. The scribe must learn to edit the technician's history of present illness, also noting any information the patient offers to the doctor. The scribe must record positive or negative responses to prove that the doctor asked certain questions. A weak history may prevent the use of an otherwise-justified higher-level office visit code. For instance, a history that misses the appropriate elements of the chief complaint may necessitate a level-3 evaluation and management code, instead of the otherwise-appropriate level-4.

Standardization. Once the exam begins, the scribe must note the findings verbatim. The use of electronic pre-determined-option exam forms help greatly, particularly if there is adequate space for findings for either eye.

Observation. The scribe must remember to watch the exam closely and correlate verbal dictation with the eye being examined (i.e., the physician might accidentally say left when examining the right eye).

No assumptions. The scribe must not assume to mark "normal" for any element the doctor fails to dictate. Never copy forward previous findings. Always ask for clarification.

Documentation continues. The scribe should continue to take detailed notes of the physician's assessment even after instruments have been set aside.

Physician’s right hand. The scribe constantly assists the ophthalmologist and the patients. They may hold a patient's head in the slit lamp, administer drops, or change tonometer tips. An experienced scribe will locate forceps or other supplies before being asked. The scribe also may relay instructions to the patient, including lid hygiene, post-operative care, or scheduling information for surgery.

Steps to improve conversation documentation

Become a good listener. Lots of information will be presented to you from patients and doctors so always keep your ears open and actively listen. You will have to summarize the conversations including the reasoning behind a decision, such as being more compliant with glaucoma medications vs. undergoing SLT.

Increase typing speed and accuracy. Several online resources can evaluate your initial typing speed and offer exercises to improve speed and accuracy. For example, listen to a conversation and try typing it out. Utilizing the QWERTY keyboard maximally allows faster transcribing.

Understand the system. There is no universally utilized EHR, so it is crucial to learn the features of the unique system you will use. Master how to create notes, modify notes, insert procedures or radiology reports into notes, and input proper diagnosis and disposition information.

Learn medical terminology. Learning medical terms allows you to transcribe faster and to gain a better understanding of the patient's course of treatment.

Always be aware of patient confidentiality. In this profession, you will be exposed to a plethora of information—you are required by law to keep this information confidential.

Understand additional orders. Understanding which studies are ordered and why will make it easier to recognize the plan of action and medical decision-making when the physician dictates them to you. Do not hesitate to ask the provider why they placed certain orders or what the results of the study indicate. In my experience, most are happy to clarify any confusion.

Learn the physician’s practice style. To ensure efficiency and improve productivity, work with the doctor to understand what order examination steps will take place and be prepared to execute that order with every patient encounter.

Be aware of patient's care plan. The best scribes are always on top of their charting and aware of every aspect of the patient’s care plan. This requires respectfully prompting physicians to place orders on the off chance they forget to do so. Making physicians aware that laboratory or radiology studies have returned also aids the patients and lets the providers know you are paying close attention. This directly benefits patients by making sure everything is in place to take care of their needs.

Overcoming challenges

Interpersonal fit: There are no two members of a medical team who work more closely together than the doctor and the scribe, especially in those practices fortunate enough to have a dedicated scribe per doctor. Understanding each other's personality style, communication style, and motivation goes a long way in improving both verbal and non-verbal communication. This is something that can be achieved even in an environment where scribes are cross-trained within the practice, though perhaps more gradually.

The scribe must respect the doctor's level of education and clinical expertise, and the doctor, in turn, must respect the level of the scribe’s education or on-the-job experience and clinical abilities. If respect is missing in the relationship, it is likely that trust is also missing. Each must trust that whatever the other is doing is in the best interest of the patient and the practice.

There will be times that, when reviewing a chart note, a doctor is unhappy with the scribe’s documentation of the visit. They should have a private conversation and include the clinical supervisor to explain how the information should be documented and why. The scribe should be a participant in the ensuing discussion as to how to best accomplish the task. Some key phrases and/or education materials should be shared so scribes achieve the same understanding. This option lets scribes know they are not meeting the doctor's expectations but gives them the criteria and tools to do so. Scribes should continually strive for personal and professional development by improving their knowledge and skills and by making a commitment to live by the mission, vision, and goals of the practice.

There may also be times that the scribe is met with some obstacles that prevent thorough documentation. A common obstacle: not being able to hear the physician’s voice during an exam. If the conversation cannot be heard, it cannot be documented thoroughly. Scribes should let the doctor know about the problem, so that modifications can be made. Asking the doctor to speak in your direction, more slowly, or even to adjust her speaking volume, can help immensely. Ask the doctor when it would be best to repeat the findings, whether it be in the exam with the patient or afterwards, so that everything is documented appropriately.

Time restraints: Self-organization, the ability to prioritize, and knowing the location and availability of resources and equipment, are key factors in being a successful scribe, especially when time is a concern. Discuss expectations with the physician and, if possible, come to an understanding on who completes which task in the encounter to ensure efficiency and completeness. Seek out help from others who scribe when delayed in an exam lane after the doctor has moved on.

Training: Physicians and the management team must agree on a common "language" for anatomical structures, ocular and systemic diseases, medications, and any terminology that might be practice-specific. This will insure that documentation is consistent across all providers and scribes. Abbreviations should include the standard terms for healthy findings (i.e.clear for cornea) as well as those phrases used to describe pathological findings (i.e. cell and flare). Today’s electronic records have included frequently used terms.

Common medical terminology, orders and documentation preferences should be outlined clearly. Competency should be checked at regular intervals and feedback from current scribes and physicians should be taken into consideration when revising guidelines and establishing new policies.

Resources for scribes

Colleagues and physicians: The best scribes are those who have experience in direct patient care first. Assistants and technicians who workup patients can process information efficiently, will make excellent scribes. To make this transition: follow the doctor through several exams to become familiar with where to document exam findings and learn the doctor’s flow. Scribes can also be a starter posisiton in the clinic. When starting out, follow work-up technicians to observe how they get their information for the doctor and see how tests are performed.

Joint Commission on Allied Health Personnel in Ophthalmology (JCAHPO): The Ophthalmic Scribe Certification (OSC) is designed to test the knowledge of creating and maintaining patient medical records under the supervision of an ophthalmologist. These records include the documentation of a comprehensive patient history, physical examination, medications, lab results, and other essential patient information. This examination is CMS Stage 2 Eligible Professional Meaningful Use Core Measure compliant. (Of note, certification is no longer required under MIPS.) Additionally ICAHPO offers contuinuing education courses and webinars geared toward educating scribes.

The American Academy of Ophthalmology: The AAO’s website is a fantastic resource for learning about ophthalmic terminology and ocular diseases as the information is written in lay terms.

There are several books available on that offer guidelines for the new scribe. And just as there are courses online for technicians, the same websites have information for scribes. OP