Today’s post is written by one of our medical scribes, Andrew Garrigue.
As I turn into the hospital entrance early on a Sunday morning, the parking lot will be my first indication of what I’m heading into. Sundays are usually one of the two busiest days of the week in an Emergency Department, in tight competition with Mondays. Today, it looks surprisingly empty. I know that won’t last.
The Role of a Medical Scribe
I’m scribing for Dr. S. today. Over the last 15 months we’ve developed not only a productive working relationship, but also a rhythm, and a form of shorthand. My role as his scribe is clear; I am his assistant, and I do what he wishes me to do, how he wishes me to do it. But beyond that, knowing how he relates to patients, the series of questions he asks and the phrases he uses, means I can anticipate his needs, and better support his efforts to treat his patients as quickly and effectively as he can.
The day starts off steadily, with a substance-abusing non-compliant homeless man who presents with suicidal intentions, a woman with sudden onset hip pain, and two cases of abdominal pain accompanied by dysuria. We dig in.
How Medical Scribes Save Time
We have our own way of working together. I use a WOW (Workstation on Wheels), and follow him into the first room. He conducts his interview of the patient, gathering what he needs for the HPI (History of Present Illness) as well as the medical and social history. I know the questions he asks, and have developed a format to take quick notes. He conducts a physical exam, and moves on to the next room. He is already determining what tests he wants to run, what medicine or other treatment he may wish to get started. Because I will be taking care of filling in certain sections of the EMR (Electronic Medical Record), he can move forward to putting in orders, and giving instructions to the nurses, meaning patient care is in motion very quickly.
I refer to my notes to enter the pertinent info into the various sections of the EMR. In this hospital, we use the Cerner system, and it is my role to complete the HPI and the ROS (Review of Systems) and I do so with precision, using the answers to Dr. S’s questions to cover such areas as the full nature of the chief complaint, and the supporting info that can help determine a diagnosis, such as any recent changes in medications, any non-compliance, any additional medical history which could be relevant. It is my role to get this info into the EMR as quickly as possible, so that when Dr. S returns to his computer to review the patient’s care, he can quickly find each piece of information, in its proper place within the EMR. This allows him to efficiently continue forming a diagnosis and plan for treatment.
Before I leave the EMR, I move to the Impression and Plan section to add my Scribe Attestation, an important step which shows I have entered information into the chart. It is Dr. S’s responsibility to review my entries, and add to them or correct them as necessary.
I join him in another patient’s room. Dr. S. already has the laptop ultrasound cart there, and he is preparing to conduct an ultrasound exam. He fills me in on the situation, going through his sets of questions that will end up in the HPI and ROS, and I take notes in an improvised shorthand. I quietly enter the info into the EMR, keeping an eye on Dr. S. and listening to his observations. Knowing the ultrasound drill, I grab some paper towels for Dr. S., to wipe off the patient and the machine when he is through. It is a small thing, but Dr. S. appreciates that the towels are ready when he is done, and I sense the patient appreciates that, too. We always aim to provide excellent customer service, and part of my role is to mirror the level of personal attention and respect to the patient (and family) that Dr. S. provides.
His exam completed, Dr. S. wheels away with the cart, and I quickly complete the HPI and ROS and add my Scribe Attestation. Part of my job is to record the “story” of the CC (Chief Complaint), and an important element of this is the timeline. When was onset? Abrupt or gradual? Did it worsen? When? Did the nature of the pain change? How so and when? Did other symptoms present at a certain stage in the timeline? All this info has been gathered by Dr. S. and relayed to me, and the responses have now been recorded in the EMR
Efficiency is of the Essence
Back at the Nursing Station where Dr. S. sits at his terminal, I pull my WOW alongside a counter and, given some down time before another batch of new patients, review our current patients. I check to see if any labs or radiology results are in. If they are, I’ll go the Medical Decisions area of the EMR, and enter those results into the chart. My goal is to get them into the chart as quickly as possible, so that when Dr. S. reviews that chart, everything that can be in there is in there, ready for his study. A nurse may ask me to relay something to Dr. S., and I’ll do so. Dr. S. may ask me to page the Hospitalist, or follow up with the lab to see why the results aren’t back yet. Time is of the essence, as is information, and my role as scribe is to gather the info as quickly as possible, to assist Dr. S. in his work. Naturally, the aim is to treat patients as quickly as possible, and offer them relief as quickly as possible. An additional reason for this emphasis on speed, especially in the ED, is that at any moment a veritable flood of patients will arrive in our waiting room. We want to be caught up when that inevitable surge comes. We joke that on Sundays those surges are somewhat predictable. There will be a surge after the early church services let out, and another surge when the later services let out.
Sure enough, there’s a surge in the early afternoon – falls, shortness of breath, a 19-year-old having a stroke, an episode of C-diff. We’re moving quickly, with hyper-focused efficiency.
Suddenly, there’s a call for a STEMI alert in room 4. It goes out over the intercom, and a minute later another call over the intercom for a Cardiologist. All attention quickly goes to that. Nurses gather quickly. Dr. S. has been assigned to that patient, and he takes command in the early moments, gathering info, giving instructions to the nurses. The cardiologist arrives, Dr. S. briefs him, they confer, and then the cardiologist takes over.
Because we were caught up on existing patients, and moving speedily through the rush of new patients, this STEMI crisis did not mean a drop in customer service in the ED for our patients. Naturally, this crisis took priority for a while, but soon enough that patient was stabilized and moved “upstairs” for admission, and the rush of new patients was treated as expediently as possible. There was some down time again, briefly, to look for labs and radiology and other results, to fill in the EMR for Dr. S., and assist him with patients who would either be discharged, admitted or transferred.
We did not have any patients transferred during our shift, but Dr. M. did. A young child would need to be airlifted to a nearby facility that has superior abilities to treat children. Dr. M’s scribe, a young woman studying to be a doctor, assisted Dr. M. with this by contacting the facility, obtaining the usual information, and preparing the transfer paperwork for Dr. M. to complete. They have a different way of working together than we do. She does not use a WOW, relying strictly on her notepad while in the patient’s rooms. Otherwise, it is very similar; she follows Dr. M. into the room, takes careful notes while he does the interviews, and then they confer closely, back at their computers, with Dr. M. filling in any blanks, giving the results of his physical exam and more. Dr. S. fills in the physical exam portion of the EMR himself for his patients, as that is his preference.
Every doctor in the ED who uses a scribe dictates how the relationship works, and how the scribe will assist him or her in completing the EMR, and processing the discharge, if that is the plan. While each scribe has been trained by Scribekick on the medical terminology, software, process, rules, regulations, and more, each doctor has an ability to customize what they wish the scribe to do and how it will be done. The doctor is in control of the relationship, and it is really a partnership honed by the doctor to suit the doctor’s needs and preferences.
Generally speaking, the goal of the Emergency Department is to provide the best care possible for patients, in the most efficient way possible. The scribe’s role in speeding up the extensive charting process pays dividends for patients in that they get treated more quickly, hopefully feel relief more quickly when relief is possible, and are on their way home more quickly, if they are fortunate enough to be discharged. An additional dividend is realized by the doctors, when they reach the end of their shift, and they are not as exhausted as they might be, and they are not faced with hours of charting still to complete. About a year ago, after reading an article about Emergency Room doctor burn out, I asked Dr. S. why he doesn’t get burned out. Without missing a beat, he looked up with a sparkle in his eye:
“I use scribes. And that really helps.”