I have had the opportunity to scribe for Dr. Grace Lee in endocrinology and Dr. Kenneth Mancher in family medicine. Working with these two doctors has allowed to me learn about two interesting specialties and learn about different providers’ preferences.
I am no longer working with Dr. Lee, but I had a great experience scribing for her. I would prepare the patient’s chart through pulling forward the previous note, deleting the interim history, and updating the labs section. Dr. Lee preferred that I log onto Fluency for Scribes about 15 minutes before the shift in order to ensure additional pieces of information, such as recent surgeries, DEXA scans, and ultrasounds, were included. During each visit, I would input the HPI (history of present illness) and ROS (review of systems). Dr. Lee liked to provide thorough instructions for her patients, and I would often enter these into the Patient Instructions section. After the visit, we would review the physical exam, and Dr. Lee would dictate the assessment and plan.
With Dr. Mancher, I do not prepare the charts until the patient arrives. The notes are created using NoteWriter and the CPE (complete physical examination) or Return Visit templates. I add in the most recent labs and apply the default ROS and physical exam if applicable. During the visit, I fill in the HPI, enter the visit diagnoses, update the ROS and physical exam, write down EKG results dictated by Dr. Mancher, enter orders, and include detailed information in the Patient Instructions. There are also smart lists relating to health maintenance in the note, and I make selections based on what was discussed during the visit.
With both doctors, I have found it important to ask questions. They are usually more than happy to answer your questions, and it allows you to record the correct information. Working as a scribe for AQuity Solutions has allowed me to learn a lot about medicine, patient-physician relationships, and the electronic medical record.
(Aislynn lives in California and currently scribes remotely for a family medicine physician in Connecticut.)
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