You will learn 5,000 new words in your first year of medical/PA/NP school and, depending on how long you scribe, you may well learn a significant chunk of these. And yet, this is not the most important thing you will learn as a medical scribe. The most important thing you will learn is the back and forth, the ebb and flow, the taking and recording of medical history. Even in this day of advances in imaging and laboratory testing, the medical history is still what is used to make a correct diagnosis 75-80% of the time. You will not learn most of what there is to know about history taking during your time as a scribe, because you will not have learned the data needed on which to base your history taking, but if you pay attention to what questions your provider is asking, and how the patient answers those questions, you will be well served in your future career. As a medical scribe you will learn to do what healthcare providers have learned to do, namely, to record in the medical record not so much what is said as what is meant. You will learn, in other words, to synthesize, to translate, as it were, from a two-person dialogue which often rambles into a coherent story. That story is the history.
I start my shift well before the provider is scheduled to begin work and do what he or she will do. I review and take notes about each patient scheduled and then look over the medication and problem lists. I ask myself why the patient is taking a given medication, then note which problems are chronic or acute, and finally decide which problem(s) may be most important to the health of the patient. For patients who are returning to discuss results of laboratory or imaging results, I make sure I have already made copious notes about the results. For patients who are returning for followup visits for recent onset, acute illness or for more chronic conditions, I always look back over prior visit, ER, and consultant notes to review the nature of prior diagnoses and symptoms, and will keep these in mind as today’s visit begins to flow.
At the end of the patient visit, in conjunction with the provider, I make sure all diagnoses in the assessment section are correct, with resolved problems no longer appearing on the active problem list, and that all diagnoses and medications have been addressed in the plan/discussion section. My scribe attestation signature goes at the bottom of the note only after I have proofread what has been entered, after which I release the note for the provider to review. Then on to the next patient!
(Spike is a retired physician and businessman who now scribes remotely from Arizona for family practice providers in the San Francisco Bay area.)
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