the growth years: medical scribing

Upon graduating from undergrad with a Bachelor’s of Arts in Psychology, Bachelor’s of Science in Human Biology & my lil creative writing minor, I immediately entered the field of medical scribing. Let’s rewind to how I got there, because I know many of those that are reading this are pre-medical students seeking a little guidance (which I completely commend & if you have specific questions hmu).

It’s funny because even 7 years later, I still remember the exact moment that one of my friends introduced me to the idea of medical scribing. I was at the local Thai restaurant in our college town and I remember her walking in and we hadn’t seen each other in a while, we were closer during the first two years of college, but drifted after a while. She asked me if I was still pre-med, and I enthusiastically said yes, but had minor setbacks due to failing courses, etc. She asked me if I had heard of medical scribing, and I responded, nope. She gave me a little insight into what scribing was, how it was the ultimate pre-med experience and it was new and would look great on my application. She ended by mentioning how I should enroll in medical terminology at the local community college, she had given me all the info, and I was enrolled that week, as the course had just started. This moment was fate working like a charm, until this day I am so extremely grateful for my friend because she changed the course of my life! Before this moment I had no idea what I was going to do after graduating, but the universe sent my friend into the Thai restaurant that day and set up the next two years of my life.

What is medical scribing?

Anyway, that was a long intro, but it goes to show you never know how life works out. So what is medical scribing? More than half of a physician’s job is documenting what they do. Yup, read that again. Due to legal issues, liabilities and more – physician’s have to document every thing they do. Nurses have to document everything they do. Dentists have to document everything they do. Every single healthcare provider must document every little thing. From medications provided, each interaction, each physical exam, the patient’s entire history, each procedure, each phone call referral, and more – everything needs to be documented. Medical scribes are trained to help a physician do all that legal documentation. They do exactly what the title indicates. A scribe is defined as,

a person who copies out documents, especially one employed to do this before printing was invented.

Oxford Languages via google

**Just a mini disclaimer: this is my experience as an emergency department medical scribe, each scribe’s experience is based off of their site and speciality. I learned after meeting other medical scribes that each scribe has a unique experience**

So what do scribes do exactly? Based on my experiences, medical scribes are physician’s writing hands, legit. The physicians do everything, the scribes documents each step. You are literally following in the every footsteps of a future that you are looking forward too. It’s like shadowing with more responsibility. After my two-week training, which consisted of medical terminology, learning the actual Electronic Medical Record (EMR) system the hospital system, the legalities, and a total of five shifts with a trainer (and a sixth one for those who needed the extra practice) – I was ready to be on my own. Training shifts were nerve-wracking because I felt like I was in the way. The last couple trainings, the trainer watched me – and the truth is my success was based on how fast or slow the emergency department was like. Some shifts were 10 patients while others were 30 patients. Also, it was not just about scribing. I had to make sure my provider was up to date on all the labs and procedures. I had to keep tabs on all labs, images and calls we were waiting on. So if my provider did not see that Room 6 had an appy, it would be my fault. It was as if I was already on rotations for med school, moreso it was already as if I was a resident. If a patient came into the ED coding, I was responsible for talking to the paramedics and documenting what they did prior to entering the ED. If I missed a detail, it could potentially compromise my provider’s chart, or even patient care. You never knew what you were going to get in the ED. Some of those patients were quick charts, while other complex. Obviously, I made it through training – haha.

A Day in the Life of an Emergency Department Scribe

So what was the actual position like? I worked in a level 2 trauma center. It was a good medium of everything. So scribes had to be prepared for every patient case. Their complexity shouldn’t slow me down. My chief scribe would schedule us monthly, there were many different shifts: ones that started as early as 4am or ended as early as 7am. Yes, I’ve done my fair share of night shifts, tbh, they were my favorites! Let’s break it down:

Each provider had a different style of how they like things done, thankfully my scribe team had made a document of each providers style. At the start of my shift I would open that document so the provider knew I was on the same page as them. Then I would look at the board. The EMR board would let me know which patients my provider got signed out (if the previous provider passed down patients), so that I could keep tabs on any labs we would be waiting on. Next the provider would pick up new patients, if there were any on the board. Some days were chill, and there wouldn’t be patients to pickup until later, other days we would walk into a messy ER with TONS of patients to see.

Once my provider picked up patients I would meet them at the provider dock and then escort them to the patients room, with my handy dandy laptop – yes the first ER i worked at had laptops on wheels for scribes to take into the patients rooms with the provider. And here’s where the fun would start. Let’s take you through a hypothetical patient encounter.

  1. Ideally my provider looks over to me, and says ready? And I give them a big smile and nod and join them as we go to our first patient room.
  2. The provider goes about their patient encounter as they normally do, by first getting the History of Present Illness (HPI) – during this time I am typing everything super fast or circling things in the chart that are relevant:
    1. What brings you in today?
    2. What makes it better? What makes it worse?
    3. On a scale of 1 to 10, 10 being your worst pain ever, what would you rate it?
    4. Any other symptoms that go along with this? (basically going through head to toe symptoms)
      1. Fever? Cough? Cold? Runny nose?
      2. Stomach pain? Nausea? Vomiting? Diarrhea?
      3. Any weakness or tingling?
      4. Chest pain? Short of breath? Difficulty breathing?
      5. Headache?
      6. Difficulty urinating? Pain with urination?
      7. Any relevant history
        1. Has this happened before
        2. Any chronic issues
        3. Family history?
        4. Medications
        5. Allergies
  3. Then the provider moves on to Physical Exam – this is usually a template in the chart that I have to fill out whether checkboxes or written out
    1. Head to toe exam! From vital signs (such as the blood pressure, temperature, respiratory rate, heart rate) to ensuring that the patient tis alert and oriented. Normally you check off the things that are “normal” and then the provider will vocalize the abnormal findings either in the patient room or after they’ve left the room.
  4. Following the Physical Exam, the provider updates the patient on the next steps. Which usually includes ordering labs, imaging, medications and fluids. As the scribe I take note of everything and add it into the chart, I also note it down for myself so I can follow up on labs and imaging, to assure my provider sees the labs in a prompt manner. This is so crucial especially when it comes to really important images – such as for an appendectomy – if that appendix is on the way to bursting the provider needs to see the images STAT so we can get the patient up to surgery.
  5. During this time, we move onto the next patient and start the cycle again. I also have to make sure the charts are filled up for the providers to review – so that they fill in whatever they need to before the patient is admitted or discharged. Some providers will go ahead and finish their charts during the shift – most leave it to the next day – it really depends on how hectic the day is!

What did I learn?

I spent two years scribing, and it was one of the best ways that I was exposed to the field of medicine. I loved it. It solidified that I could truly handle medicine. I saw everything in the ER from ear infections in children to active myocardial infarctions. I saw patients from every walk of life. It exposed me to the inequities of healthcare. The odds and ends of insurance. And reminded me that medicine isn’t perfect. Each provider was different. Some more kind than others. Others who had become jaded by the system. I saw the best and worst of medicine within the ER.

I also learned how crucial collaboration was the field. Your patient’s outcome is based on how effective the team worked together. If you and your nurses, respiratory therapist, pharmacist, EMTs, emergency technicians and radiologist, etc were not on the same page – this could compromise your patient’s care. I remember seeing great teams but then really poor teams as well.

Also, being a scribe did help me for my “doctor” class in medical school. Our class is called History & Physical – and this is a class that teaches the basic mechanics of patient encounters – and it has been such a breeze because I was a scribe. I already know how to interact with a patient and chart my encounters because I spent two years doing it! From medical terminology to learning about electronic health records and even the confidentiality portion of it, check, check and check.

All in all, if you have the opportunity to become a medical scribe, do it! If you’re on the field of if you want to be a physician, nurse or PA, do scribing! You’ll see all parts of the team and figure out which role you want to play for life. It was great. And honestly, you are not limited to scribing in the ER. Scribes have become such a prominent part of healthcare in all different fields, they make providers more efficient – they are being used in all sectors of health! I encourage you to check out a local clinic, hospital etc to see if they can give you more info on their opportunities. I know with the pandemic things have gone virtual but I still believe there’s so many opportunities for learning and growth even virtually!

Let me know if you have any questions, concerns or clarifications. Hope this helped! Next post of this series will focus on my post-bacc experience, as that is what I did following two years of scribing.

Sending tons of love & don’t forget, I believe in you, now go on and believe in yourself too!

Love,

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