I am the primary scribe for Dr. Stanley Michael at Cape Regional in New Jersey. He is an orthopedic surgeon specializing in joint replacement of the shoulder, knees, and hips. A typical day for me starts with an early wake up to get my children off to school. I tend to the animals so I can focus my attention on the work ahead for us that day. Fifteen minutes prior to start time, I clock in to document all of the currently scheduled encounters for the day in Fluency For Scribing. I review whether the patient is there as a new or existing patient, and this generally gives me an idea of how thorough the encounter will be. I gather any snacks or drinks and use the restroom before my provider logs into Fluency for Scribing. After he is sent the first chart, I will click on the encounter, so that while Dr. Michael reviews the previous encounters, I can include in the H&P any diagnostic imaging or laboratory test results that he may have reviewed in order to save time when typing the Assessment and Plan. While he is examining the patient, I apply the physical exam templates for typical areas above and below the joint he is focusing on during this visit. He and I have adopted a list of auto-text dot phrases, which helps when charting, especially for a brief encounter. After each encounter, we act as sounding boards for anything that we might have missed. He will always make sure to take time to review the charts to ensure he and I are both accurate.
The most important advice I can give is to learn from your provider. Do not be afraid to ask any questions, no matter how intimidated you may be! If you are uncertain of anything, speak up. It is better to double check than to let an encounter be signed off on that has to be fixed later. Also, remember that your team leader is a great place to go when you are uncertain of how to proceed.
(Kimberly lives on the East Coast and scribes remotely for Dr. Stanley Michael of Cape Regional Medical Group, which is located in Cape May, New Jersey.)
Are you a premed? Join Diverse Medicine now. It's free!