Do your scribes suck? Do just mine suck? Do I suck? Am I doing it wrong? You tell me.

[RustedFox]

I can be wrong in my line of thinking, but recently I've been concluding that using a scribe actually slows me down.

1. I enter room with scribe. Most of the time, they have a workstation on wheels and they stand there with the charting program (Cerner) open on one half of the screen, and (of all things) Notepad open on the other. They make notes on the notepad, and try to synthesize a HPI after the initial encounter.

Criticism: Over half of the time, I end up deleting their entire HPI and dictating it myself using DragonSpeak. Their HPI often lacks duration, direction, or some other quality that makes it difficult to understand just what is going on with the patient. This becomes even more time-consuming with the histrionics and the "pan-positive" ROS patients.

2. For physical exam findings, I have tried stating what I want out loud to the scribe when in the room. I don't understand why they do this, but most of the time they put a shorthand version of what I dictate in NOTEPAD, and then try and expand that into the PE section later on. The scribes lack the vocabulary and medical knowledge to do this reliably. For example. I will state aloud:

"Focused physical exam of the left lower extremity reveals no obvious deformity or fracture. Most importantly, the entire limb is pink, warm, and well-perfused - and the limb is without any threat to its neurovascular integrity. There is modest tenderness and fullness to the popliteal fossa, most clinically consistent with a Baker's cyst. There are no markings or discolorations to suggest underlying vascular pathology such as DVT or PVD."

Instead, this is actually what I got last night: "FOCUS EXAM: No FX. Entire limb is pink and profuse with no threat to NV exam Bakers cyst no marks or color for vasculapathy."

Criticism: I have tried on no fewer than twenty occasions (without exaggeration) to say directly to the scribes: "Listen, I just want you to be a microphone. I say it. You type it ... capital letters, periods, full sentences and all." I spoke my punctuation aloud to them in the exam room. They still go through their "Notepad -> Cerner" workflow. Then, I have to re-do it myself. DragonSpeak gets it right the first time, all the time. With autotexts and macros, my job is even easier. I type "GE", and I get my "This extremity is safe and stable" speech.

3. I have been told to use the scribes to help with workflow by asking them to remind me when "X" radiology study has returned, or when "Y" labs are back. With a ratio of 1 scribe to 2 or 3 providers... the scribe is more often off in another exam room rather than paying attention to the tracking board. This leaves me just doing it by myself anyways.


I can be wrong. I would love to find a good use for the scribes, but I'm really trending in the other direction now.

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[KinesiologyNerd]

Sounds like your scribes suck. Also, 1 scribe for multiple providers sucks.

When I was a scribble we were trained by the docs we worked for (not some faceless scribe company) and I think that helped a lot.

 

[heroesinahalfshell]

Sharing scribes sounds like a recipe for disaster. I have worked at 2 different hospitals with scribes, one place the scribes were mediocre to decent while one of the facilities I work at now the scribes are amazing. Some of the things that I have noticed about the scribes at my current place that make them a huge resource is that they go through a few days of training and then will have quite a few shifts with one of the more experienced scribes before they fly solo. Also during this time both the mentor scribe as well as the doctor will give feedback to the hiring group/person and on a few occasions a few scribes have been let go after some of the shadow shifts due to it being clear that they cannot cut it. Also most of the doctors will also at some point go over a general physical exam, ROS, etc. that all the scribes share so that when they work with me they know what templates I like to use. Likewise they keep a list of preferences for each doctor, for example: Dr. A likes all labwork brought into his note, Dr. B likes for you to look up most recent previous visit/admissions/etc for pt.

But if the scribes suck, then they suck, sounds like you have tried to help them to help you without any luck. Maybe you can ask your group that you do not want to use the scribes and instead whatever your expense for using the scribe is they add to your pay?

 

[BJJVP]

To me, scribes can be good at making a note that can be coded out as a level 5 chart. If that's all you expect out of them, then they may speed you up or at least make your day way less painful.

However, in my opinion, there is no way a person with minimal medical training will ever be able to do what the scribe companies claim they will do. I don't expect that they will create a chart that makes medical sense, gives a clear idea of my medical reasoning, & is accurate while being medicolegally defensible without slowing me down. It takes me 30-90 seconds to dictate a good note that I can live with. It's just not fair to compare a scribe to that. In addition, there is no way on earth that they can do all of that and also be expected to put in discharge instructions, get blankets and water for patients, & prompt me that patients are ready for a disposition...especially if they take 30 minutes for lunch during the shift. No way. It just won't happen. I don't even think an experienced PA with typing skills could do all that for me.

If anyone has scribes that can do all of the above, then I would wager that your doctors were either just slow, or working inefficiently (possibly due to an inefficient charting system) before the scribes were implemented or possibly your ED is not that busy.

To me, the greatest benefit of scribes is that they take away the relatively meaningless but mentally taxing task of charting. This leaves me with more mental energy and a greater ability to concentrate during my busy day of extreme multitasking filled with interuptions. Of course, the drawback is having an inferior chart when compared to dictation.

 

[witzelsucht]

I would offer that the increase in scribes (compared to "back in my day") is probably watering down the pool. Everyone wants to work 12 hours a week to keep it on the premed resume. When I worked in the community we had three scribes for 12ish docs. I knew everyone's preferences. We all worked 24-36 hours a week (as gap year+) so we learned faster. We also used an EMR which allowed the docs to share their own macros so they could say "just do the HPI and use my cholecystitis ROS/PE/MDM."

Looking at the kiddos scribing at my residency program, they look bored and less interested, but its also always a new face, because they work like a handful of short shifts each.

Or maybe I sucked as a scribe just as much and didn't realize it.

 

[Willfrye027]

I used to be a scribe and a scribe chief involved in all the training and hiring and whatnot (currently med student). Your scribes might suck, but I think you are asking too much of them. It sounds really easy to just type verbatim what you are dictating, but more than a sentence or two is actually pretty tough...especially when you don't really know or understand the words/medicine. And one scribe to multiple providers really sucks for everyone involved.

The real $/purpose of scribes is click all those friggin buttons (especially with cerner...) so that your chart doesn't get downcoded for clicking in 9 instead of 10 review of systems and crap like that. Scribes with more experience and good training might be able to write a decent HPI, on simple patients. Your are bound to get frustrated asking for much more than that-and even the best scribes make plenty of mistakes.

Some of the docs I used to work with would dragon in the HPI (if complicated pt or scribe sucks), exam, and MDM and the scribe would do the rest. It also gives the scribe a few extra seconds to look ahead-alert you to labs and imaging, print discharge paperwork, start charts on the next patient, etc. You get the best of both worlds-all the important "medicine" stuff is done by you, and the scribe does all the time consuming clicking.

Also, some personalities/people just cannot be good scribes. There are some that just don't get it.

 

[dchristismi]

Maybe your scribes suck. A good one makes a world of difference because I think it does make the mental taxation easier. I can go from room to room and see more than I could remember in one go around, and once you've trained the scribe how you want things, a good one does what you want. I really like being able to "dictate" EKG readings and rechecks on the fly. I do all my own MDM as well as d/c instructions because I prefer to tailor to the specific case.

A sucky scribe means you're going to redo every single chart. And I've had a few. I can't imagine not having 1:1 - how the heck would they keep up?

Edited to add that with really complicated ones, I don't hesitate to dragon the HPI. (Great verb...) Same goes if I know it will spurn subpoenas. (The rapes/child abuse/some assaults.)

 

[deleted497653]

At my job, we have to pay for scribes. I tried to train a few but realized that they could never do what I wanted them to do and they tend to goof off more than I would like. They became one more person to manage so I decided to stop having a scribe and I do all my notes and I am a much happier doc for it. I do most of my charting right after seeing the pt and the rest of the clean up gets done at home; just to crosscheck and make sure everything is just the way I like it. I am kinda ocd when it comes to charting and only my notes are good enough to me.

 

[GeneralVeers]

I'm blessed with having pretty decent scribes, but that being said, I only use scribes because I want them to fill out the busywork that no one ever reads, like HPI, physical exam, and ROS as well as enter labs and X-rays. I generally write a 1-2 paragraph summary of the patient's care, lab results and clinical though process on my own. That is the section that most people actually read.

 

[ucbsmd]

We have pretty good scribes at my program. They write the HPI's in the room, click the corresponding ROS boxes for the positives (They have learned that the pertinent negatives are included when I'm obtaining the HPI and the level 5 billing ROS is done right before my exam), add in any physical exam abnormalities in addition to my standard exam and all the boxes saying I looked at the triage note, vitals and nursing notes. I also use them for dictating the straight forward MDM such as patient with lac to finger or standard low risk chest pain discharge home per HEART score (with score breakdown). Ill have have them do time stamps for consults and anything important discussed as well as important events during the patients stay. Anything more complex than that, I will dictate the MDM using dragon to fully capture my thought process, events during ED stay and treatments performed.

Things that have made them more useful to me are
1. Creating my own templates/macros that cover my standard ROS questions and exam
2. Setting expectations at the beginning of the shifts the first few times I work with a scribe for what I am looking for them to do
3. Sending them feedback as I review and sign charts. Most scribes I work with are looking to improve the quality of their work and respond well to notifying them of things they can do to be more helpful or provide better documentation

 

[DoctorMedic]

Sounds like it's your scribes. I have found mine to be very responsive and generally accurate. For the more complicated pt or sicker pt or anything concerning I write my own MDM section or at least augment theirs. This way there is something in my own words in the chart. Things like AMA etc I do myself as well. That way I can make sure all the stuff I want charted like "pt appears to have capacity and able to make decisions for themselves at this time" which most scribes will botch. But generally they are great at clicking the boxes and a general HPI.

 

[swamprat]

The few times I have used scribes in the one hospital we work at I didn't really like it. Felt like I was modifying things and re-reading it a lot. I can see if you work with the same scribe and establish a relationship (at least for the academic year before they go off to medical school) it may be better. I hate charting. I will say when you have a room of kids that that Mom decided to bring to the ER all with a cold it is nice to have a scribe chart while your in there examining them all. Otherwise I prefer to do it on my own.

 

[namethatsmell]

I've got scribes that are really hit or miss and my group doesn't have Dragon. Man, I wish we had Dragon.

Anybody know of a voice to text app that's HIPAA compliant for the iphone? It would be awesome to be able to dictate MDMs.

 

[hypnix]

I've got scribes that are really hit or miss and my group doesn't have Dragon. Man, I wish we had Dragon.

Anybody know of a voice to text app that's HIPAA compliant for the iphone? It would be awesome to be able to dictate MDMs.

If you have Cerner, there is an iOS app and dictation works pretty well actually.

How are scribes not 1:1 with a doctor? No way could I share a scribe at my shop. Overall, most are very good and learn your preferences very fast. I do my own MDM though as someone said above it's the part that people read.

 

[da8s0859q]

Ours kind of suck, and I stopped using them. But that might just be because I hold them to too-high standards.

They're (mostly) premeds and various other undergrad- or transitioning-type folks. Not to sound offensive, but it's like @BJJVP said: can't really expect them to compare to the kind of standard to which I hold my own documentation.

I don't want just a 99285 chart. Any ****ing monkey with a typewriter can do that. I want a 99285 chart which tells a story, is complete, uses proper English, contains a minimum if ANY Dragonisms or other grammatical or typo type mistakes, doesn't contain bull****, doesn't contain nonsense in the HPI (why do our scribes here do this? Stop that...), doesn't contain nonsense "visit summary" stuff which is meaningless prose, doesn't include erroneous or irrelevant comments from patients which have nothing to do with the evaluation, and which has a solid, thorough but appropriate MDM with cogent thoughts and which I'd be happy to see again if anything ever came of it. I have had one single scribe do this maybe 60% of the time for me. The rest sucked.

We pay for our scribes. No thanks. I'll pocket the money and save the end-shift frustration.

 

[RustedFox]

Ours kind of suck, and I stopped using them. But that might just be because I hold them to too-high standards.

They're (mostly) premeds and various other undergrad- or transitioning-type folks. Not to sound offensive, but it's like @BJJVP said: can't really expect them to compare to the kind of standard to which I hold my own documentation.

I don't want just a 99285 chart. Any ****ing monkey with a typewriter can do that. I want a 99285 chart which tells a story, is complete, uses proper English, contains a minimum if ANY Dragonisms or other grammatical or typo type mistakes, doesn't contain bull****, doesn't contain nonsense in the HPI (why do our scribes here do this? Stop that...), doesn't contain nonsense "visit summary" stuff which is meaningless prose, doesn't include erroneous or irrelevant comments from patients which have nothing to do with the evaluation, and which has a solid, thorough but appropriate MDM with cogent thoughts and which I'd be happy to see again if anything ever came of it. I have had one single scribe do this maybe 60% of the time for me. The rest sucked.

We pay for our scribes. No thanks. I'll pocket the money and save the end-shift frustration.

This.

I think this should be the standard for scribes.

We don't pay them for creative writing.

I don't want nonsense in my HPI, my MDM, my anything. I hate it.... haaaate it when they write things like this:

"Patient is a 28 year old female with a history of fibromyalgia and mitral valve prolapse that says her chest pain is worse than ever. Her mom is with her and says its really, really bad. She says she's dizzy, passed out twelve times today, and that her allergy to toradol makes her head explode and she dies every time. She has a surgical history significant for broken toes. She denies any other complaints, but says that her hair hurts. Heart rate is running at 77 beats per minute."

Full sentences with capital letters, appropriate punctuation, and sentence content should be a requirement for 9th grade graduation, let alone employment as a scribe who is looking to get into MD/DO/PA school.

Furthermore... the job title is "scribe", not "CNN journalist" (I couldn't resist). You type what I tell you to type.

Three clicks (standard HPI, ROS and PE macros) and I get a level-5 chart. That's not enough to justify a scribe.

Can the scribe. Give me a freaking "general intern" who can communicate with patients, get me food/coffee, make phone calls, and sign paperwork. That's worth twice as much.

 

[deleted77919]

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[RustedFox]

Disagree.

Dealing with very special off service interns on a regular basis, I would definitely take a scribe instead. Scribes don't order random d-dimers, tell 80 year old women their beta HCG is positive and therefore they must be pregnant, and piss off consultants.

Both can write non-sensical notes unfortunately.

My apologies. I didn't mean an "intern" in the sense of a PGY-1 resident. I mean an intern in the sense of "do what I tell you to do and learn from it".

I think "page" might be the better term.

 

[PeachTea_]

I was a lead scribe (which included hiring, training, firing and managing the program overall) for several years before medical school. It sounds like you have bad scribes but I've learned that it really comes down to the motivation of the individual scribe to learn about medicine, in terms of the quality you get.

My best scribes were the ones who were quick learners, anal about detail, studied up on their medical terminology, listened and followed through with what their provider said, and were constantly looking to go above and beyond. Unfortunately, I most scribes are not of that caliber. Most scribes end up being of minimal help or even creating more work for the provider as you've found out (surprise, scribe wrote that baby is "lethargic" because mom said so, despite baby happily cooing and playing with a toy).

It definitely can be a fantastic experience for premeds but many times, the doc suffers.

 

[F0nzie]

I was a scribe for 3 years before med school. $5.50 an hour. I did documentation, tracked labs + X-rays, wrote rxes, and prepared discharge summaries. ED docs were free to see more patients and focus on clinical work. I remember at times seeing 50+ patients per shift.

This was over 10 years ago, though-- there was no EMR. We had "T-sheets" or templates for every problem i.e. chest pain sheet, abdominal pain sheet, headache sheet. Everything fit on a single sheet of paper and it was easy to document focused exam findings. I could blaze through the documentation and be done with everything except the A/P before the ED doctor left the room.

Now I am a physician and hire my own employees to run my business. If I tried today to hire someone with the necessary qualities of an ED scribe, finding the right candidate would not be easy. This person would have think quickly, move quickly, learn fast, type fast, multitask, be attentive to detail, be organized, have good recall, anticipate several steps ahead, understand the needs of the ED doc... and while this is familiar territory to many of us it's fairly uncommon for most people to work in this capacity. An average candidate will not help your bottom line and simply be a waste of resources.

I think you should consider a better hiring process and perhaps a more efficient user interface for your workstations on wheels.






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[RustedFox]

I was a scribe for 3 years before med school. $5.50 an hour. I did documentation, tracked labs + X-rays, wrote rxes, and prepared discharge summaries. ED docs were free to see more patients and focus on clinical work. I remember at times seeing 50+ patients per shift.

This was over 10 years ago, though-- there was no EMR. We had "T-sheets" or templates for every problem i.e. chest pain sheet, abdominal pain sheet, headache sheet. Everything fit on a single sheet of paper and it was easy to document focused exam findings. I could blaze through the documentation and be done with everything except the A/P before the ED doctor left the room.

Now I am a physician and hire my own employees to run my business. If I tried today to hire someone with the necessary qualities of an ED scribe, finding the right candidate would not be easy. This person would have think quickly, move quickly, learn fast, type fast, multitask, be attentive to detail, be organized, have good recall, anticipate several steps ahead, understand the needs of the ED doc... and while this is familiar territory to many of us it's fairly uncommon for most people to work in this capacity. An average candidate will not help your bottom line and simply be a waste of resources.

I think you should consider a better hiring process and perhaps a more efficient user interface for your workstations on wheels.
Sent from my iPhone using SDN mobile app

You can hire/fire your scribes? I can't. I work for a CMG. Lolz on me.

 

[Willfrye027]

You can hire/fire your scribes? I can't. I work for a CMG. Lolz on me.

Lol those are some pretty funny examples of charts. When we hired scribes the main thing we looked at was "will this person eventually get into med school?" That usually selects for more...talent. It definitely sucks that you have no control on who to hire. You can always be mean to the ones that suck and they will trade out of your shifts

Kudos if you have no problem with all the charting. I will say that our site had a month without a single chart downcode, missed procedure, or missed ancillary-try that without scribes. Our program was expensive but easily pays for itself in billing quality of charts alone, not to mention productivity. Hopefully your experience improves and you get some kids with an actual future in medicine-definitely a mutually beneficial relationship.

 

[GeneralVeers]

Scribes aren't good if you are OCD and need to read over every word written. The fact is that 99% of your charts will never be read by anyone except a coder. The completely useless stuff like HPI elements, ROS, and PMSH are best done by someone making $10/hour, not by us.

 

[ballinsncbirth]

I can be wrong in my line of thinking, but recently I've been concluding that using a scribe actually slows me down.


Criticism: Over half of the time, I end up deleting their entire HPI and dictating it myself using DragonSpeak. Their HPI often lacks duration, direction, or some other quality that makes it difficult to understand just what is going on with the patient. This becomes even more time-consuming with the histrionics and the "pan-positive" ROS patients.

2. For physical exam findings, I have tried stating what I want out loud to the scribe when in the room. I don't understand why they do this, but most of the time they put a shorthand version of what I dictate in NOTEPAD, and then try and expand that into the PE section later on. The scribes lack the vocabulary and medical knowledge to do this reliably. For example. I will state aloud:

"Focused physical exam of the left lower extremity reveals no obvious deformity or fracture. Most importantly, the entire limb is pink, warm, and well-perfused - and the limb is without any threat to its neurovascular integrity. There is modest tenderness and fullness to the popliteal fossa, most clinically consistent with a Baker's cyst. There are no markings or discolorations to suggest underlying vascular pathology such as DVT or PVD."

Instead, this is actually what I got last night: "FOCUS EXAM: No FX. Entire limb is pink and profuse with no threat to NV exam Bakers cyst no marks or color for vasculapathy."



I can be wrong. I would love to find a good use for the scribes, but I'm really trending in the other direction now.

bro you are being waaayyyyy to hard on your scribe. You expect them to write down verbatim everything you say in the room ? You have to realize how hard it is to write a sentence like that verbatim when you don't understand anything in the sentence, trying to keep paying attention to what your about to add , and write it without spelling mistake AND listen to your next sentence, all the while trying to type on a hold a portable laptop .

I work with scribes. they are invaluable and I wouldn't work a place without them . That kind of exam you should probably put yourself during your review. scribes are t make sure they bill a chart with all the level 5 nonsense, as well as allow me to not have to try a write down or remember useless things like ROS, MED HX , SURG hx , chart ekgs , or progress notes and labs xrays , consults, ALL for 20-25 patients after my shift is over. They in my mind are expressly for Billing purposes not medicolegal documentation. I can seen 30 patients while concentrating on medical care, spend more time with people instead of charting, AND in between relax and surf SDN while the scribe hammers out the charts (which I am actually doing right now on shift)


I always add a paragraph at the end, summarizing the patient complaints, course, significant PE findings ,LABS, Treatment,s MDM , reasons why I did or didn't do X , for medicolegal documentation to supplement the scribes billing documentation

 

[GeneralVeers]

bro you are being waaayyyyy to hard on your scribe. You expect them to write down verbatim everything you say in the room ? You have to realize how hard it is to write a sentence like that verbatim when you don't understand anything in the sentence, trying to keep paying attention to what your about to add , and write it without spelling mistake AND listen to your next sentence, all the while trying to type on a hold a portable laptop .

I work with scribes. they are invaluable and I wouldn't work a place without them . That kind of exam you should probably put yourself during your review. scribes are t make sure they bill a chart with all the level 5 nonsense, as well as allow me to not have to try a write down or remember useless things like ROS, MED HX , SURG hx , chart ekgs , or progress notes and labs xrays , consults, ALL for 20-25 patients after my shift is over. They in my mind are expressly for Billing purposes not medicolegal documentation. I can seen 30 patients while concentrating on medical care, spend more time with people instead of charting, AND in between relax and surf SDN while the scribe hammers out the charts (which I am actually doing right now on shift)


I always add a paragraph at the end, summarizing the patient complaints, course, significant PE findings ,LABS, Treatment,s MDM , reasons why I did or didn't do X , for medicolegal documentation to supplement the scribes billing documentation

Exactly. This is how I use scribes. Those who are unsatisfied with them are not using them correctly, or set their expectations too high.

 

[emergentmd]

OP,

1. You are expecting way too much from your scribe. If I were your scribe, I probably would fail you too and I probably have more EM experience than you.

2. You are an ED doc. How can you be OCD. EM is full of stuff we can't control. Let it go alittle, relax. If you have such high expectations for all of your scribes, you will be setting yourself up for many bad days. You might as well just not use scribes.

3. I work at different places, same charting system. One place scribe and one not. I do save about 1 hr from my work with a scribe b/c they do the HPI/PE. I do the MDM. I just tell them to Mark everything negative and enough to satisfy the pencil pushers. Keep it simple, very little positives, exams almost always negative. Less positives, less I have to explain.

Keep it simple, it will make your life easier.

 

[goodoldalky]

I am with Fox on this one. I used scribes for a couple of years and a while back finally concluded that it's not worth it. I paid $10 an hour for a scribe and my RVU/billing/coding productivity is not increased with them (although I don't do much low acuity and that is where active productivity benefit has been described). If you are productivity based you have to run the numbers to see if they are worth it.

Most scribes cannot create a medical record that accurately reflects what actually went on during the visit without significant micromanagement. The good scribes that can do this are around for a few months and get into medical school. IF you can hire and train your own scribe and keep them for a year plus at a time working with them consistently, I do believe the efficiency can be improved, but most scribe agencies do not work like this.

 

[RustedFox]

OP,

1. You are expecting way too much from your scribe. If I were your scribe, I probably would fail you too and I probably have more EM experience than you.

2. You are an ED doc. How can you be OCD. EM is full of stuff we can't control. Let it go alittle, relax. If you have such high expectations for all of your scribes, you will be setting yourself up for many bad days. You might as well just not use scribes.

3. I work at different places, same charting system. One place scribe and one not. I do save about 1 hr from my work with a scribe b/c they do the HPI/PE. I do the MDM. I just tell them to Mark everything negative and enough to satisfy the pencil pushers. Keep it simple, very little positives, exams almost always negative. Less positives, less I have to explain.

Keep it simple, it will make your life easier.

Your criticism is well-received. I'm not all that OCD; its just that I don't see the benefit to a scribe whenever:

1. My DragonSpeak is faster and more accurate.
2. My Macros and AutoText are all set up for ROS/PE/MDM.

I've actually said to the scribe this week after seeing a turbo low-acuity patient or three (say, peds head injury/fever that isn't there, etc) "Just cancel your chart so I can DC them already."

 

[emergentmd]

I am a great test case for scribes. Both hospitals with similar high acuity/Sick/Old population. Same system, same charting, same order entry, different city.

1. Hospital A - Efficient, see about 2.3pt/hr, NO scribe. See about 20 pt/shift. I leave usually leave 30 min after next doc comes in. Has Dragon. spend 2-4 min per chart.
2. Hospital B - Super inefficient, See about 2.7/hr, SCRIBE. See about 30 pts/shift. I leave right when next guy comes in. NO dragon. Spend about 30-60 sec per chart

So all in all, I would say I save about 60-90 min having a scribe. Keep your expectations low, don't overwhelm them with expectations. I use them to ask pts something I forget, put instructions on discharged pts, grab me stickers, follow up on labs/consults, get lunch, etc...

I tell them to keep all History simple. Exam neg unless I say its positive. I do the MDM and add any positive to my hx or exam that fits.

Remember to be nice to them. They are usually smart and want to go into the health field. They don't know what you know. They will make mistakes, they are human. Don't expect too much even if there are scribes that are great. Scribes are a revolving door and they leave in 1-2 yrs if that much.

Sit back and realize what great jobs we have. ED docs are probably the least physically difficult job in the ED but get paid 10-20x everyone else. . We sit around alot surfing the internet while everyone is running around dealing with patients.

 

[Transmogrifier]

1:1 scriberovider ratio or nothing. I think your scribes just don't have time to do everything you're asking. They are not court stenographers. They need time to come back and sit down and convert everything into a coherent note after leaving the room. If they have to immediately go with another doc to see another patient they'll never have time to do more than dump the quick notes into the chart.

Certainly some programs train their scribes better than others. Some pre-meds, no matter how smart, are not cut out to be scribes. It should be easy to fire a scribe during their initial training or first few shifts if they suck. Unfortunately the best scribes are experience and experienced scribes go off to med school. They should also be functioning as a mini-clerk for you: notifying when results back, doing some paperwork, sending pages, etc.

Scribes can be awesome.

 

[emergentmd]

I am a great test case for scribes. Both hospitals with similar high acuity/Sick/Old population. Both in the Same System, same charting, same order entry but different city.

1. Hospital A - Efficient, see about 2.3pt/hr, NO scribe. See about 20 pt/shift. I leave usually leave 30 min after next doc comes in. Has Dragon. spend 2-4 min per chart.
2. Hospital B - Super inefficient, See about 2.7/hr, SCRIBE. See about 30 pts/shift. I leave right when next guy comes in. NO dragon. Spend about 30-60 sec per chart

So all in all, I would say I save about 60-90 min having a scribe. Keep your expectations low, don't overwhelm them with expectations. I use them to ask pts something I forget, put instructions on discharged pts, grab me stickers, follow up on labs/consults, get lunch, etc...

I tell them to keep all History simple. Exam neg unless I say its positive. I do the MDM and add any positive to my hx or exam that fits.

Remember to be nice to them. They are usually smart and want to go into the health field. They don't know what you know. They will make mistakes, they are human. Don't expect too much even if there are scribes that are great. Scribes are a revolving door and they leave in 1-2 yrs if that much.

Sit back and realize what great jobs we have. ED docs are probably the least physically difficult job in the ED but get paid 10-20x everyone else. . We sit around alot surfing the internet while everyone is running around dealing with patients.

 

[deuist]

I've seen them run from excellent to terrible, which I can never understand as I give them a written out template of how I want the charts written. "Just copy and past this template and only change the items I tell you to. Don't put anything else on the chart." At the end of the shift I still get tons of errors that need correction as when I tell the scribe, "The patient is in distress and uncomfortable appearing," only to get a physical exam that says, "General: Well appearing, no acute distress. The patient is in distress and uncomfortable appearing."

 

[Willfrye027]

I've seen them run from excellent to terrible, which I can never understand as I give them a written out template of how I want the charts written. "Just copy and past this template and only change the items I tell you to. Don't put anything else on the chart." At the end of the shift I still get tons of errors that need correction as when I tell the scribe, "The patient is in distress and uncomfortable appearing," only to get a physical exam that says, "General: Well appearing, no acute distress. The patient is in distress and uncomfortable appearing."

When I trained scribes I would always try to get them to THINK about what they're doing. Its the ones that try to do the job like a robot without thinking that tend to struggle with stuff like that. Plus, scribes get wayyyy more out of the experience when they are thinking about things. Some docs I worked with would ask me for the differentials or diagnosis instead of just telling me what to chart-learning some of the basics as a scribe is paying dividends for me in medical school. As much as a scribe might help you, remember how much you are helping the scribe too-encourage them to think!

 

[takeurmeds02]

I would offer that the increase in scribes (compared to "back in my day") is probably watering down the pool. Everyone wants to work 12 hours a week to keep it on the premed resume. When I worked in the community we had three scribes for 12ish docs. I knew everyone's preferences. We all worked 24-36 hours a week (as gap year+) so we learned faster. We also used an EMR which allowed the docs to share their own macros so they could say "just do the HPI and use my cholecystitis ROS/PE/MDM."

Looking at the kiddos scribing at my residency program, they look bored and less interested, but its also always a new face, because they work like a handful of short shifts each.

Or maybe I sucked as a scribe just as much and didn't realize it.

I agree with this. Honestly, 9/10 times, the better scribes tend to be the ones who are taking time off in between undergrad and medschool. We were the full-timers who, like you said, had time to learn faster from more exposure. The increased couple-month, premed turnover per shop is what kills the value of the process.

I scribed for two years but I sucked hard for about the first 6 months but eventually progressed to most attendings signing off on my charts with little amendments made if any between 5 different EDs in the area. There has to be a lot of patience on either side of the chart. Physicians have to understand that we can barely wipe our asses medically; our initial training in terms of terminology, pattern recognition, and MDM do not exist. Everyday is a quick teaching opportunity. On the same token, the scribe must be absolutely willing to learn, think, and push themselves to get it right; this is what you signed up for. Get with it or go home.

It's not an imperfect process and like some of folks have mentioned, some attendings may need to start re-adjusting their expectations from their scribes. Appreciate what they can do to your liking and just know that some other things, you'll just have to do on your own; at least a good portion of the chart will be done. When you get a good one, the shift feels seamless but when you get bad ones, it really shows.

 

[MSmentor018]

we've got some folks that don't use scribes at all, uses dragon entirely. for me the best thing about the scribe is putting in the chart all the BS stuff that coders want to see and to document my times: ex walked down the entire hallway and reeval/brought a blanket/snack to pt x. they just follow right behind me and type in a pre set macro, or what i did....etc. also adding in x ray results/labs/ekg readings, time critical care note....etc. those little things save me a ton of reminders to do it later. I've got a few scribes that are phenomenal, even pull up x rays for me and ask for a read, tell me about abn values. I think we work at the same shop so I hope you get them. but sure, you get a new or bad scribe and it blows. you're having to re do the entire HPI, maybe re eval note. I give clear expectations before going into the shift of what i want to see in the notes (ex: ultrasound procedure notes) including what they are interested in so I do a little teaching and other expectations, like lunch.

 

[tsbqb]

and she dies every time

lol

 

[MareNostrummm]

When I trained scribes I would always try to get them to THINK about what they're doing. Its the ones that try to do the job like a robot without thinking that tend to struggle with stuff like that. Plus, scribes get wayyyy more out of the experience when they are thinking about things. Some docs I worked with would ask me for the differentials or diagnosis instead of just telling me what to chart-learning some of the basics as a scribe is paying dividends for me in medical school. As much as a scribe might help you, remember how much you are helping the scribe too-encourage them to think!

I've been an ED scribe at 3 different hospitals for about 8 months and whats funny is that the OCD doctors LOVE working with me and even request it but the fastest doctors that do not even read their charts before signing (unless its very high acuity) are always trying to push me to go unrealistically faster and faster (do you want good sensible documentation, or crusty half-assed charts?). I find that scribes are often pushed to be like a robot because they are trying to finish the chart ASAP by utilizing an algorithm so that they can move onto the next 3-5 patients that are piling up...

I go carefully through my charts and make sure everything is thorough and makes sense. I've been told that I am one of the most conscientious scribes, and my charts are often signed with minimal editing, but its at the expense of sheer speed unfortunately. I could easily document the examples that OP mentioned. However, when I read some of the fastest scribe's charts they can be nonsensical... unless they are already very experienced. Like clearly missing basic things to increase the reimbursement that they would have caught by sacrificing some speed.

On many occasions I have shown up to shifts and have had physicians give me charts from patients they saw a week ago(!), on top of the ones they are currently seeing on the shift. Within the first 30 minutes of your shift you're already behind 8-9 charts rather than the cushy 1-3. So I can see why they end up with nonsensical charts and expect the physician to clean them up (my hands are going to fall off if I type any faster)

 

[CCmetal94]

I'm a scribe an I never knew anybody did a 1:1 ratio. I work with a pool of like 10 different docs. I have friend that scribe for a different company and will sometime scribe for the PAs and NPs. I agree it would be better to stick with one doc.

 

[jw3600]

I'm a scribe an I never knew anybody did a 1:1 ratio. I work with a pool of like 10 different docs. I have friend that scribe for a different company and will sometime scribe for the PAs and NPs. I agree it would be better to stick with one doc.

I think he meant at one time. Like for a single 8 hour shift the scribe is charting for 1 provider.

God I hate that ****ing word.

 

[shoal007]

Please refer to me as physician or doctor. I now refer to pcps as pmd so there is no confusion.


Sent from my iPad using Tapatalk

 

[jw3600]

Please refer to me as physician or doctor. I now refer to pcps as pmd so there is no confusion.


Sent from my iPad using Tapatalk

Where I'm from PCP is primary care physician. Did they try and steal that initialism too?

 

[shoal007]

Where I'm from PCP is primary care physician. Did they try and steal that initialism too?

Correct. Primary care provider.


Sent from my iPad using Tapatalk

 

[Psai]

Where I'm from PCP is primary care physician. Did they try and steal that initialism too?

Everything you use they will try to steal. Even the letters NP were chosen to look as similar to MD as possible. It's a pathetic game of play pretend.

 

[RustedFox]

Everything you use they will try to steal. Even the letters NP were chosen to look as similar to MD as possible. It's a pathetic game of play pretend.

This.

This actually happened to me three days ago.

Patient sent to ER by PCP (who is some dip**** NP that I know from other dealings) for STAT ultrasound of the abdomen to r/out "intraabdominal hemorrhage" from MVC 5 days ago. Repeat: FIVE days ago.

Reason being? The patient noticed that the bruise on her left anterior abdomen (seat-belt/lap-bet line) had gotten bigger and coalesced together in some parts. - And she is scheduled for exploratory lap in 2 days time for nonspecific pelvic pain. She's worried about.... *dun-dun-DUNNNNN* ... INTERNAL BLEEDING!

RustedFox: "Who is your family care doctor?"
*******: "I don't see the doctor. I see the NP; "Jenny McJennyson" she knows me. I've never even seen the doctor."

My physical exam:

GENERAL: Patient is a fat, bloated late 40-something who has clearly given up on life 15+ years ago. She loves saying things like "this is how a REAL woman SHOULD look." + 5/5 Fibromyalgia self-pity. Forget about conditioning and general fitness. HR = 72 and regular. BP = 155/75. Social history: Single and smokey. (Surprise!!!)
HEENT: NC/AT. EOMs are fat. + Taco bell sauce to left cheek. PERRL.
CHEST: Breath sounds are fat, but symmetric. Generally sweaty and gross. + Chalupa breath. Heart sounds = regular rate, fat rhythm. No murmurs. The heart actually whispered to me thru the stethoscope: "Please, help me."
ABDOMEN: Seat belt bruises are present in the expected pattern on an obese abdomen with loose adiposity. I can fully grab the small (2-3 cm) hematoma in question in the LLQ between my fingers, which is well-demarcated and defined. To assume that it would extend to even the superficial surface of the abdominal wall would require 8-10 cm of depth thru adipose tissue, which is clearly not present. THEN, it would have to somehow magically penetrate the fascia and the abdominal wall musculature... five days after the accident.
NEURO: CN 2-12 = Fat. Focally and globally neurologically intact.
EXTREMITIES: 3+ baking bread edema to the bilateral feet. Feet crammed in shoes two sizes too small for vanity purposes. Shoes clearly too expensive than should be practical for this person. Nicotine stains are somehow present.


It gets better. Patient is pissed that I can't order ultrasound because I don't have them in-house (patient decided to show up at 11:45 PM... after her typical 10 PM fast food pig-out), even though midlevel-******* sent her to the ER at 6pm from the urgent care ("quittin' time! yabba dabba doo!"). Patent says: "The DOCTOR sent me HERE to get the ULTRASOUND !!" Forget trying to explain that my physical exam findings and general common sense obviate the need for this unnecessary exam. This one is just not having it.

Your Command:

[FIGHT]
[RUN]
[MAGIC]
[ITEM]
[DEFEND]


Moral of the story, to properly reply to Psai's post: These MLPs out in the community.... there are more and more of them every year, and none of them have a whit of sense about them.

 

[southerndoc]

This.

This actually happened to me three days ago.
It gets better. Patient is pissed that I can't order ultrasound because I don't have them in-house (patient decided to show up at 11:45 PM... after her typical 10 PM fast food pig-out), even though midlevel-******* sent her to the ER at 6pm from the urgent care ("quittin' time! yabba dabba doo!"). Patent says: "The DOCTOR sent me HERE to get the ULTRASOUND !!" Forget trying to explain that my physical exam findings and general common sense obviate the need for this unnecessary exam. This one is just not having it.

And your patient gets a Press-Ganey next week. Booyaa!

 

[Tenk]

This.

This actually happened to me three days ago.

Patient sent to ER by PCP (who is some dip**** NP that I know from other dealings) for STAT ultrasound of the abdomen to r/out "intraabdominal hemorrhage" from MVC 5 days ago. Repeat: FIVE days ago.

Reason being? The patient noticed that the bruise on her left anterior abdomen (seat-belt/lap-bet line) had gotten bigger and coalesced together in some parts. - And she is scheduled for exploratory lap in 2 days time for nonspecific pelvic pain. She's worried about.... *dun-dun-DUNNNNN* ... INTERNAL BLEEDING!

RustedFox: "Who is your family care doctor?"
*******: "I don't see the doctor. I see the NP; "Jenny McJennyson" she knows me. I've never even seen the doctor."

My physical exam:

GENERAL: Patient is a fat, bloated late 40-something who has clearly given up on life 15+ years ago. She loves saying things like "this is how a REAL woman SHOULD look." + 5/5 Fibromyalgia self-pity. Forget about conditioning and general fitness. HR = 72 and regular. BP = 155/75. Social history: Single and smokey. (Surprise!!!)
HEENT: NC/AT. EOMs are fat. + Taco bell sauce to left cheek. PERRL.
CHEST: Breath sounds are fat, but symmetric. Generally sweaty and gross. + Chalupa breath. Heart sounds = regular rate, fat rhythm. No murmurs. The heart actually whispered to me thru the stethoscope: "Please, help me."
ABDOMEN: Seat belt bruises are present in the expected pattern on an obese abdomen with loose adiposity. I can fully grab the small (2-3 cm) hematoma in question in the LLQ between my fingers, which is well-demarcated and defined. To assume that it would extend to even the superficial surface of the abdominal wall would require 8-10 cm of depth thru adipose tissue, which is clearly not present. THEN, it would have to somehow magically penetrate the fascia and the abdominal wall musculature... five days after the accident.
NEURO: CN 2-12 = Fat. Focally and globally neurologically intact.
EXTREMITIES: 3+ baking bread edema to the bilateral feet. Feet crammed in shoes two sizes too small for vanity purposes. Shoes clearly too expensive than should be practical for this person. Nicotine stains are somehow present.


It gets better. Patient is pissed that I can't order ultrasound because I don't have them in-house (patient decided to show up at 11:45 PM... after her typical 10 PM fast food pig-out), even though midlevel-******* sent her to the ER at 6pm from the urgent care ("quittin' time! yabba dabba doo!"). Patent says: "The DOCTOR sent me HERE to get the ULTRASOUND !!" Forget trying to explain that my physical exam findings and general common sense obviate the need for this unnecessary exam. This one is just not having it.

Your Command:

[FIGHT]
[RUN]
[MAGIC]
[ITEM]
[DEFEND]


Moral of the story, to properly reply to Psai's post: These MLPs out in the community.... there are more and more of them every year, and none of them have a whit of sense about them.

[MAGIC] --> [SONOSITE] --> [PLACEBO MEDICINE] --> It's super effective! ******* fainted!

 

[MSmentor018]

This.

This actually happened to me three days ago.

Patient sent to ER by PCP (who is some dip**** NP that I know from other dealings) for STAT ultrasound of the abdomen to r/out "intraabdominal hemorrhage" from MVC 5 days ago. Repeat: FIVE days ago.

Reason being? The patient noticed that the bruise on her left anterior abdomen (seat-belt/lap-bet line) had gotten bigger and coalesced together in some parts. - And she is scheduled for exploratory lap in 2 days time for nonspecific pelvic pain. She's worried about.... *dun-dun-DUNNNNN* ... INTERNAL BLEEDING!

RustedFox: "Who is your family care doctor?"
*******: "I don't see the doctor. I see the NP; "Jenny McJennyson" she knows me. I've never even seen the doctor."

My physical exam:

GENERAL: Patient is a fat, bloated late 40-something who has clearly given up on life 15+ years ago. She loves saying things like "this is how a REAL woman SHOULD look." + 5/5 Fibromyalgia self-pity. Forget about conditioning and general fitness. HR = 72 and regular. BP = 155/75. Social history: Single and smokey. (Surprise!!!)
HEENT: NC/AT. EOMs are fat. + Taco bell sauce to left cheek. PERRL.
CHEST: Breath sounds are fat, but symmetric. Generally sweaty and gross. + Chalupa breath. Heart sounds = regular rate, fat rhythm. No murmurs. The heart actually whispered to me thru the stethoscope: "Please, help me."
ABDOMEN: Seat belt bruises are present in the expected pattern on an obese abdomen with loose adiposity. I can fully grab the small (2-3 cm) hematoma in question in the LLQ between my fingers, which is well-demarcated and defined. To assume that it would extend to even the superficial surface of the abdominal wall would require 8-10 cm of depth thru adipose tissue, which is clearly not present. THEN, it would have to somehow magically penetrate the fascia and the abdominal wall musculature... five days after the accident.
NEURO: CN 2-12 = Fat. Focally and globally neurologically intact.
EXTREMITIES: 3+ baking bread edema to the bilateral feet. Feet crammed in shoes two sizes too small for vanity purposes. Shoes clearly too expensive than should be practical for this person. Nicotine stains are somehow present.


It gets better. Patient is pissed that I can't order ultrasound because I don't have them in-house (patient decided to show up at 11:45 PM... after her typical 10 PM fast food pig-out), even though midlevel-******* sent her to the ER at 6pm from the urgent care ("quittin' time! yabba dabba doo!"). Patent says: "The DOCTOR sent me HERE to get the ULTRASOUND !!" Forget trying to explain that my physical exam findings and general common sense obviate the need for this unnecessary exam. This one is just not having it.

Your Command:

[FIGHT]
[RUN]
[MAGIC]
[ITEM]
[DEFEND]


Moral of the story, to properly reply to Psai's post: These MLPs out in the community.... there are more and more of them every year, and none of them have a whit of sense about them.

that's the funniest and most accurate physical exam I've ever read!!

 

[RustedFox]

[SUMMON FINAL FANTASY AEON]

They're called Aeons now ?

I quit playing after FFX. Its no longer Final Fantasy, its "Final Science Fiction Teen Romance"

 

[RustedFox]

[MAGIC] --> [SONOSITE] --> [PLACEBO MEDICINE] --> It's super effective! ******* fainted!

Critical Hit! ---> Terminated.

 

[Psai]

This.

This actually happened to me three days ago.

Patient sent to ER by PCP (who is some dip**** NP that I know from other dealings) for STAT ultrasound of the abdomen to r/out "intraabdominal hemorrhage" from MVC 5 days ago. Repeat: FIVE days ago.

Reason being? The patient noticed that the bruise on her left anterior abdomen (seat-belt/lap-bet line) had gotten bigger and coalesced together in some parts. - And she is scheduled for exploratory lap in 2 days time for nonspecific pelvic pain. She's worried about.... *dun-dun-DUNNNNN* ... INTERNAL BLEEDING!

RustedFox: "Who is your family care doctor?"
*******: "I don't see the doctor. I see the NP; "Jenny McJennyson" she knows me. I've never even seen the doctor."

My physical exam:

GENERAL: Patient is a fat, bloated late 40-something who has clearly given up on life 15+ years ago. She loves saying things like "this is how a REAL woman SHOULD look." + 5/5 Fibromyalgia self-pity. Forget about conditioning and general fitness. HR = 72 and regular. BP = 155/75. Social history: Single and smokey. (Surprise!!!)
HEENT: NC/AT. EOMs are fat. + Taco bell sauce to left cheek. PERRL.
CHEST: Breath sounds are fat, but symmetric. Generally sweaty and gross. + Chalupa breath. Heart sounds = regular rate, fat rhythm. No murmurs. The heart actually whispered to me thru the stethoscope: "Please, help me."
ABDOMEN: Seat belt bruises are present in the expected pattern on an obese abdomen with loose adiposity. I can fully grab the small (2-3 cm) hematoma in question in the LLQ between my fingers, which is well-demarcated and defined. To assume that it would extend to even the superficial surface of the abdominal wall would require 8-10 cm of depth thru adipose tissue, which is clearly not present. THEN, it would have to somehow magically penetrate the fascia and the abdominal wall musculature... five days after the accident.
NEURO: CN 2-12 = Fat. Focally and globally neurologically intact.
EXTREMITIES: 3+ baking bread edema to the bilateral feet. Feet crammed in shoes two sizes too small for vanity purposes. Shoes clearly too expensive than should be practical for this person. Nicotine stains are somehow present.


It gets better. Patient is pissed that I can't order ultrasound because I don't have them in-house (patient decided to show up at 11:45 PM... after her typical 10 PM fast food pig-out), even though midlevel-******* sent her to the ER at 6pm from the urgent care ("quittin' time! yabba dabba doo!"). Patent says: "The DOCTOR sent me HERE to get the ULTRASOUND !!" Forget trying to explain that my physical exam findings and general common sense obviate the need for this unnecessary exam. This one is just not having it.

Your Command:

[FIGHT]
[RUN]
[MAGIC]
[ITEM]
[DEFEND]


Moral of the story, to properly reply to Psai's post: These MLPs out in the community.... there are more and more of them every year, and none of them have a whit of sense about them.

best physical exam ever. I could copy/paste it and that's like half of my patients