Doctors who have reached their breaking point with tedious EHR data entry are finding relief with medical scribes – online and in-person.
Increasingly, medical scribes are becoming a fixture in the healthcare setting. With the ever-expanding requirements to document patient care and EHRs now a permanent fixture in medical centers, many doctors refuse to work without a scribe to support them. Savvy doctors are discovering that they no longer need to be the ones populating Epic, Cerner, Allscripts, and countless other EHRs. If you’ve reached the breaking point and want to hire a medical scribe or a medical scribing service, here are some day-to-day recommendations to make the endeavor a success:
1. Introduce Your Medical Scribe to Your Patients. Whether you work with an in-person or remote scribe, it’s a courtesy to let your patient know your scribe’s role and how they allow you to better focus on your patients instead of the electronic medical record.
2. Respect Your Patient’s Wishes. Sometimes, patients are uncomfortable with a medical scribe in the exam room or may not want their visit recorded. In these cases, ask your scribe to step out of the room or stop the recording. Remember, you can still save time in these instances by dictating the clinical findings to your scribe after the visit.
3. Position Your Recording Device Sensibly. In asynchronous scribing scenarios, where you will be recording the patient visit for a medical scribe to type later, make sure you don’t leave your recorder in your pocket. And if your patient speaks softly, be sure to parrot back what they say so your scribe can enter those details in the chart.
4. Identify Your Patient. Again, in an offline scribing scenario, especially if your recordings don’t include video or your medical scribe doesn’t have access to your patient schedule, be sure to identify your patient by their name. This will ensure that your medical scribe enters the data in the electronic health record for the correct patient.
5. Be a Descriptive Narrator. If your scribe isn’t in the room, be sure to speak anything that the scribe won’t be able to infer without context from you. For instance, nonverbal communication, like a patient’s head nod, won’t be something your scribe will be able to document unless they are in the room or can see the encounter via a video feed.
6. Articulate Exam Findings. Explain the plan to your patient, which will simultaneously help your scribe enter it in the EHR. Likewise, during or after the visit, state the physical examination and any abnormal findings that should appear in the patient’s chart. This will ensure that you’ll find what you’re expecting to see in the medical record.
7. Feel Free to Dictate. Vocalize anything you want your medical scribe to capture verbatim in the patient’s medical record. This will save you time from making edits when reviewing the scribed charts later.
8. Upload Visits Individually. If you’re recording your visits for a virtual scribe to work on asynchronously, record each visit as a separate file. Mobile apps and telemedicine platforms can make this easy to do. Also, be mindful about uploading the recordings consistently throughout the day so your scribe can populate the EHR data quickly.
9. Give Feedback. Communication is the cornerstone of any successful doctor/scribe partnership. Make sure to give feedback to your medical scribe, especially in the beginning, so they can learn your preferences. Ask your scribe for feedback as well. Experienced medical scribes will often have suggestions that make your life much easier.
For more tips and guidance on launching a successful medical scribing initiative in your practice, contact an experienced medical scribing company like Athreon. Athreon has developed successful medical scribing, transcription, and speech recognition solutions for healthcare clients of all sizes and medical specialties. For a free medical scribe service consultation, contact Athreon at 800-935-0973 or service@athreon.com.