Nuances In Medical Scribing : 6 Practical Tips To Make It Work

Medical scribes are a key part of the medical community. They work closely with doctors, nurses, health care administrators and other team members to ensure that patient care is timely and effective. Learn all about being a medical scribe here!

According to the Joint Commission, a medical scribe is an unlicensed employee hired to input information into an electronic health record (EHR) or chart at the instruction of a physician or licensed independent practitioner. Scribes work in doctor’s offices, hospitals, emergency rooms, long-term care homes, public health clinics, and ambulatory care centres. They work as independent contractors for healthcare organisations, physicians, or other licensed independent practitioners.Most physicians spend 1.5 to 4 hours daily on EHR software to compile clinical documentation. This results in overwork decreased productivity, and burnout among doctors. Medical scribes are crucial in reducing physician burnout. They eliminate clinical document burden and EHR usability concerns.Physicians have used medical scribes to assist with clinical documentation load and EHR-related data entry. However, there are numerous difficulties in medical scribing operations in both hiring through a scribe service vendor or hiring the scribes directly. This post aims to provide practical advice on improving the efficiency of medical scribe operations in the physician’s office setting. We will be discussing in detail on the below

Why Do I Need A Medical Scribe ?

Hiring A Medical Scribe

What Skills Should A Medical Scribe Have?

Scribe Onboarding Protocol

Evaluation & Monitoring Of Medical Scribes

1. First Thing First: Why Do I Need A Medical Scribe?

The first step is to define the pain points you want to address with the induction of the medical scribe. It’s critical to understand why you’re employing a scribe. Physicians typically cite the following pain points:

EHR system usability issues.
Slow system response time.
There isn’t enough time for documentation.
Clinical notes backlog.
Medical terms take longer to spell check and edit.
Patient data search takes a longer time
Quality of notes
Revenue loss as a result of excessive time involved in paperwork

If this sounds familiar, a Medical Scribe could be of great assistance.The next step would be arriving at the time lost daily due to the identified pain points. The time spent in documentation or other activities you gain from inducting a scribe will be the key input in working out the cost before the scribe and aid in measuring the program’s success. We will see more about this in the subsequent sections.

Physicians must set care entity set clear and specific goals. Goals can include increasing revenue, provider productivity, patient satisfaction, timely record authentication, or improving provider morale. Establishing particular, measurable objectives for the medical scribe program may involve an interdepartmental team that includes multiple disciplines. Regardless, all goals should be clearly stated and metrically tracked.

2. Don’t Hire A Medical Scribe If You Can’t Find Answers To This.

The pain points you endure in clinical documentation may look valid on the face of it for hiring a scribe, but for a medical scribe program to succeed and sustain itself, a return on investment is required. There are two criteria to the question of when.

1. A medical scribe program should result in significant cost reductions or help you in improving revenue.

2. When you a ready to make changes to your workflow to accommodate scribing.

ROI on scribing

Typically, when you cannot accommodate additional patients owing to excessive documentation time, or you are spending extra hours in a clinic or at home to catch up on paperwork, it is time to hire a scribe. An objective assessment would give you confidence that a medical scribe program has the potential to sustain and succeed is an essential second step.The conventional rule of thumb is that utilising a scribe increases productivity by roughly 15%. The hourly fee for these scribes was $20.51 per hour.A 19-minute reduction in duration of stay resulted in a $26.91-per-hour savings in cubicle expenditures per patient. The total amount saved was $51.66. After deducting the scribe’s fee, The savings per scribed hour were US$ 31.15. An 8-hour workday saved US$ 252 a day, and a 20-day work month saved US$ 5040.The doctor saved US$ 5040 per month by hiring a scribe. The physician decided it was time to engage a scribe. Clinicians already performing higher than the benchmark should start using a scribe.Even if the savings are zero, it may still make sense because it reduces the burden of documentation for doctors and allows them to spend more time with patients.It becomes problematic when you cannot add the patient to the saved cubicle due to the Medical scribe addition. In this case, the cost of care rises.In a nutshell, to achieve financial savings, practices should have unmet demands to increase productivity through scribes. If clinicians are not productive at baseline, they may not have enough demand for their services, so they may not be able to generate the additional productivity requirements to make the scribe program work.

3. Hire the best Medical Scribe by process

Minimum knowledge, experience, and education qualifications
Definition of roles (i.e., scribe vs. provider)
Responsibilities and precise scope of practice

When hiring medical scribes, doctors should focus on analysing essential skills. The physicians should conduct Competency assessments and performance evaluations.

Domain knowledge – The ability to learn and apply technical (medical ideas, compliances) and professional knowledge, skills, and judgment to achieve results and efficiently serve clients. It is also essential for the scribe to understand HIPPA compliance and Meaningful Use. Learning medical terminology is similar to learning a foreign language because there are ambiguous and contradictory pronunciation standards, acronyms, abbreviations, redundant and overlapping phrases, and even slang. The scribing companies usually assess and train the scribes before being assigned to work with specific HCOs.
Understanding clinical process abilities – Scribes must understand medical terminology, workflow, clinical documentation, and regulatory issues. Practices should verify that appropriate pre-employment training is provided and, if working with a vendor, consider a contract clause to cover the organisation’s costs if a scribe’s performance is unsatisfactory.
Knowledge of tools – The ability to employ technologies (EHRs, software tools, etc.) to achieve goals and objectives and carry out work functions; applies office automation technology. Working knowledge of the software tools utilised in the process and the ability to train others. Extensive knowledge and practical expertise with at least ten EHRs

Some of the abilities required for the medical scribe to succeed are as follows:

Verbal communication – The verbal expression of ideas, thoughts, and facts is a critical need for scribes. To effectively convey ideas, use perfect grammar, acceptable body language, good tone, and intonation, recognise nonverbal cues, and respect the audience.
Listening ability – The ability to tune in to a voice or auditory message, including nonverbal clues are important skill scribes should possess. It is necessary to check the alertness and the ability to pay close attention to the speaker.
Written communication – The ability to express ideas, thoughts, and facts in writing. Ability/skill in communicating a message in writing utilising accurate language, spelling, sentence and document structure, accepted document formatting, and specific literary approaches.
Typing ability – Touch typing at a rate of more than 50 words per minute.

Tips for Practicing Listening and Typing Skills as a Scribe

Enhancing your listening and typing abilities is crucial for a scribe, and these skills can be developed with consistent practice. Here are some strategies to help you improve:

Start with Familiar Content

Choose Easy Listening: Begin with content you’re already familiar with. Consider children’s shows or beginner-level podcasts where the language is simple and the pace is slow.
Progress Gradually: As your skills improve, move to more complex sources like sitcoms or conversation-based podcasts that challenge you with faster dialogue and varying accents.

Practice with Real Conversations

Engage with Your Environment: Listen in on conversations around your home or office. Try typing out dialogues between roommates, family members, or colleagues. This practice can help you get accustomed to everyday speech patterns.

Challenge Yourself

Try Commercials: Once you’re comfortable, push your limits by typing out fast-paced content like commercials. These often have quick, precise language, which can hone your ability to quickly capture spoken words.

Focus on Accuracy Over Perfection

Ignore Errors Initially: Don’t worry too much about spelling and grammar at first. Concentrate on strengthening the connection between what you hear and how quickly you can type it out. Improvement in accuracy will follow with practice.

Utilize Technology

Leverage Recording Devices: Use a voice recorder to capture conversations and play them back as you type. This allows you to pause, rewind, and replay challenging sections.

Remember, consistent practice and gradual progression are key. By regularly applying these techniques, you’ll steadily enhance both your listening and typing capabilities.

The Importance of Chart/EMR Familiarity for a Scribe

In the fast-paced world of healthcare, a scribe’s familiarity with the Electronic Medical Record (EMR) system is crucial for several reasons.

Enhances Efficiency

Understanding how to navigate the EMR allows scribes to efficiently access previous patient notes, labs, and imaging results. This skill not only saves time but also ensures that the medical team has all necessary information at their fingertips, leading to smoother patient visits.

Ensures Accuracy

A profound knowledge of how to filter and sort through various specialties or specific data enables scribes to verify details quickly. The ability to cross-check information reduces the risk of errors and ensures that patient records are accurate and up-to-date.

Supports Comprehensive Documentation

By being adept with the EMR system, scribes can swiftly add supplemental information to the patient’s chart as required. This ensures that the attending provider has a complete view of the patient’s history, which is critical for making informed medical decisions.

Facilitates Seamless Communication

When scribes are proficient with the EMR, they can assist healthcare providers in navigating the system, thus fostering effective communication and collaboration within the healthcare team.

In summary, mastery of the EMR not only enhances a scribe’s productivity but also contributes significantly to the overall quality of patient care.

4. Follow The Medical Scribe Onboarding Methodology: A Step-By-Step Guide

Turnover among scribes can be very high, considering that most of them are pre-med students. The cost of hiring, training, managing, and high turnover tends to be higher than expected. A structured approach that can reduce costs and improve the program’s success is critical. The following section outlines a methodology that practices should follow to help the new Medical scribes learn the knowledge, skills, and behaviours they need to succeed in their new organisations quickly. Some aspects of the methodology are:

Clinical documentation processes manual
Medical Scribe Formal Induction program
Hands-on training
Quality checks

The following section provides details about the methodology.

A) Clinic Documentation Processes Manual (CDPM)

To ensure medical scribes follow established workflow methodology, an internal CDPM that explains the specific workflow of the physician has to be available. CDPM serves as the Scribe Documentation Guidelines. For the new scribe, the practice should provide training as per the physician-specific CDPM. The scribes are mandated to follow the documentation guidelines outlined in CDPM for the place of service (i.e., inpatient, outpatient). Some of the sections of the CDPM and not limited to are:

The CDPM, in addition to outlining the standard documentation requirements of an encounter, also includes the separate authentication duties for the scribe.
The next section of the CDPM stresses the data entries regarding a patient’s health information
It should describe the practice’s policies and regulatory requirements for authentication of each access and on-time completion of documentation.
The process of capturing information in the exam room and entering the data in real-time, using their individually assigned security rights to access the EHR, is in detail outlined in the CDPM with screenshots of EHR.
CDPM also includes providers’ directions to the scribe on the proper responses for advisories and other alerts that may appear on the screen.
CDPM also includes the third-party payers’ specific guidelines for how a scribe documents and how a physician must apply the electronic signature
CDPM also outlines the do’s and dont’s for scribes as per the practice guidelines.
CDPM includes the policy on signing (including name and title) and dating all entries into the medical record for both electronic and manual documentation. The role and signature of the scribe must be identifiable and distinguishable from that of the physician or licensed independent practitioner and other staff.
Typical
Documentation Duties for Medical Scribes is part of the CDPM. The information entered by a scribe may include, but is not limited to:
- History of the patient’s present illness
- Review-of-systems (ROS) and physical examination
- Vital signs and lab values
- Results of imaging studies
- Progress notes
- Continued care plan and medication lists

Ascribed encounter notes should indicate the involvement of a scribe. The scribe’s note should include:

History of the patient’s present illness
Review-of-systems (ROS) and physical examination
Vital signs and lab values
Results of imaging studies
Progress notes
Continued care plan and medication lists

The provider is ultimately responsible for the contents of the document, the note should indicate:

Confirming the physician’s presence during the encounter
Verification that the provider reviewed the information
Confirmation of the accuracy of the information
Any additional information needed
Authentication, including date and time

Resources for Practicing Medical Chart Writing

Practicing medical chart writing can seem daunting, but there are plentiful resources available to help you sharpen this skill. Here’s a guide to what you can explore:

Online Resources and Manuals: The internet is a treasure trove of educational materials designed for medical professionals. Websites offer downloadable guides and practice scenarios that mimic real-life situations, which can be invaluable for honing your skills.

Practice Scenarios: Access scenarios created by educational organizations or scribe companies that challenge your ability to write coherent and accurate charts. These exercises can include both hypothetical cases and those based on actual medical cases to provide a realistic learning experience.

Physical and Interactive Practice: Enlist the help of friends or family to act out patient scenarios. This interactive form of practice not only helps with technical skills but also improves your ability to interpret and transcribe patient interactions dynamically.

Scribe Training Programs and Videos: Many organizations provide comprehensive training through video tutorials. These can be a useful way to see chart writing in action, helping you visualize the process before trying it yourself.

Mentorship and Peer Support: If you’re part of a training program or know a seasoned scribe, tap into their experience. Mentors can provide personalized feedback and suggest scenarios tailored to your learning needs.

By leveraging these resources, you can develop greater confidence and competence in writing medical charts, ultimately improving your proficiency and performance in clinical settings.

B) Medical Scribe Formal Induction Program

The purpose of a formal induction program is to help the medical scribe settle into their position in practice.A checklist specifies all the documents and information new staff will receive on their first day on the job. A short checklist to be provided for scribes is as below:

For outsourced scribes, some of the points may not apply.

An introduction to the organisation, business, colleagues, and critical stakeholders.
Code of conduct and Clinic Documentation Process Manual
Job description for the scribe with title, roles, and responsibilities.
Details of the work schedule
Copy of their employment agreement, company handbook, and HR manual
Induction and setup of workstation, phone, and IT systems
ID card, access control keys, name badge, etc
Contact list of staff members
HR must give training specifically to the organisation and role.
If the physician employs the scribe, all non-employee HR standards also apply.
Scribes must be given orientation to all information management, HIPAA, HITECH, confidentiality, and patient rights standards, just as other hospital personnel.
Practices should make certain scribes complete training on the EHR and all other requirements before moving to the hands-on training phase.
The medical scribes are provided knowledge of Healthcare Insurance Portability and Accountability Act compliance, medical terminologies, documentation structure, clinical procedures, billing, and coding processes.

It’s considered best practice to give the employees plenty of written material they can reference later to refresh their knowledge.

C) Hands-On Training

Their article more directly addresses the question “How can exposure and practice help improve a scribe’s skills?” by focusing on the process of gaining experience and the natural progression that comes with practice. Here’s how it does so:

Direct Encouragement and Reassurance: The article emphasizes that improvement comes with exposure, suggesting that practice is essential for skill development. It reassures new scribes that it’s normal not to master everything immediately and that they will improve over time.

Continuous Feedback: It mentions the importance of honest feedback from trainers, highlighting how continuous evaluation and constructive criticism can guide scribes towards improvement.

Progression to Independence: The article outlines a clear path from initial exposure and training to eventual independence, underscoring the role of practice and exposure in achieving this transition.

In contrast, Your article provides a more detailed and structured overview of the training process, without explicitly linking the concepts of exposure and practice to skill improvement in the same straightforward manner. While it discusses training levels and evaluation, it focuses more on the logistics of training rather than the benefits of exposure and practice in skill enhancement.

Why It’s Crucial for Scribes to Seek Clarification from Providers or Trainers

Effective communication is the backbone of success for medical scribes. Without a clear understanding of their responsibilities, scribes might struggle to accurately capture vital information, leading to potential errors in medical documentation. Here’s why asking for clarification is essential:

Accuracy in Documentation:

Precise medical records are paramount. When scribes ask questions, they ensure that every detail recorded reflects the provider’s intent, thus safeguarding patient care quality.

Learning and Improvement:

Interaction with providers and trainers enhances learning. By seeking clarity, scribes can overcome initial misunderstandings and gradually improve their medical terminology and charting skills.

Building Confidence:

Engaging in open dialogue fosters confidence. As scribes clarify uncertainties, they gain reassurance in their abilities, which translates to more effective and independent future performance.

Efficiency and Workflow:

Misunderstandings can lead to repetitive tasks and wasted time. Clarifying at the outset means fewer disruptions later, allowing the workflow to proceed smoothly and efficiently.

Strengthening Professional Relationships:

Regular communication with providers and trainers builds trust. When scribes show initiative by asking questions, it demonstrates their commitment to excellence and collaboration.

By consistently seeking clarification when in doubt, scribes not only contribute to the accuracy and quality of healthcare delivery but also develop their skills and confidence in a demanding field.

How Can New Scribes Improve Their Shorthand Skills for Medical Dictation?

Mastering shorthand for medical dictation is an invaluable skill that can significantly enhance a scribe’s efficiency and accuracy. Here are some practical strategies to help new scribes develop and refine these skills:

Develop a Personalized Shorthand System

Create Your Own Abbreviations: Start by identifying common medical terms you frequently encounter and develop shortcuts for them. For example, you might shorten “cardiology” to “card” or “etiology” to “etiol.”
Leverage Classroom Abbreviations: Take advantage of abbreviations taught during your training. These pre-established shortcuts can streamline your note-taking process and ensure consistency.

Enhance Listening and Typing Abilities

Improving your listening and typing skills will greatly increase the accuracy of your shorthand notes:

Practice with Audio Content: Engage with various audio materials like TV shows, podcasts, or everyday conversations. Begin with slow-paced dialogues, such as children’s shows, and gradually progress to faster speech, like sitcoms or commercials.

Diversify Your Practice: Type out conversations of family members or roommates to sharpen your ability to capture spoken words quickly without worrying about spelling or grammar.

Regular practice of these techniques will strengthen the connection between your auditory comprehension and typing reflexes, leading to more effective shorthand note-taking in a medical context.

How Can a Scribe Track Their Progress During Floor Training?

1. Embrace Regular Exposure

The key to improvement lies in consistent practice. The more shifts you complete, the more adept you’ll become. Remember, it’s normal to feel uncertain at first, so approach each shift as a learning opportunity.

2. Set Personal Benchmarks

Begin by establishing clear, achievable goals for each training session. Track your ability to accurately record information, manage time efficiently, and respond to feedback. This approach provides tangible evidence of your development over time.

3. Utilize Feedback Effectively

Engage regularly with your trainer to gain insights into your performance. An honest dialogue about your strengths and areas for improvement is crucial. This ongoing conversation allows you to tailor your focus for subsequent sessions.

4. Document Your Journey

Maintain a journal or digital log to record daily experiences and learning points. This not only helps in retaining new information but also serves as a motivational tool when you look back and see how far you’ve come.

5. Celebrate Milestones

Acknowledge when you reach significant milestones or exhibit an improvement in specific skills. These celebratory moments can boost your confidence and encourage continued progress.

By adopting these strategies, you’ll effectively monitor your advancement and enhance your capabilities as you transition towards independent work.

D) Quality Checks

The possibility of errors in documents created by scribe is a reality. These errors can affect patients’ plans of treatment, coordination of care, coding, billing, and other documentation requirements due to a lack of detailed and accurate documentation in the health record. Organisations must include scribe programs in the organisation’s comprehensive compliance program.All staff must be educated and receive ongoing training for adherence to policies, procedures, and overall management expectations. Monitoring is also a critical factor in meeting compliance. Medical scribes are subject to audit for documentation quality, privacy, and security practices.

When creating policies and procedures for implementing a scribe program, the following documentation considerations, at a minimum, should be considered.

Authentication guidelines
Regulations and guidance
Continuous training
Documentation of auditing protocols
Privacy and security auditing protocols
Certification and licensure

What Steps Should a New Scribe Take Post-Training?

After clearing the initial training stage, a new scribe can take several key steps to continue developing their skills effectively. Here’s a breakdown of the essential actions:

1. Develop a Personal Shorthand System

Creating a personalized shorthand is crucial for capturing medical dictations efficiently. This might involve:

Abbreviations: Use shortened forms like “cards” for cardiology.

Custom Acronyms: Devise acronyms that make sense to you.

2. Enhance Listening and Typing Skills

Boosting your typing speed and accuracy can significantly improve your performance. Try the following exercises:

Audio Transcription Practice: Listen to podcasts or TV shows and type out what you hear.

Gradual Complexity: Start with simple programs and gradually move to more complex dialogues, like sitcoms or commercials.

3. Get Acquainted with the EMR System

Knowledge of the Electronic Medical Records (EMR) system is indispensable. Focus on:

Navigation Skills: Learn to swiftly access and filter notes, labs, and imaging.

Augmentation Capability: Be able to find and add information with ease.

4. Practice Charting

Consistent practice in writing charts will build your confidence and skill. Consider these methods:

Use Online Resources: Explore online practice scenarios to simulate real-life charting.

Engage Family and Friends: Have them simulate medical scenarios for you to document.

5. Communicate Effectively

Don’t hesitate to seek clarification when necessary:

Ask Questions: Stay open to asking your provider for repeated information to ensure accuracy.

Utilize Trainers: If you’re nervous about interrupting providers, rely on your trainer for guidance during early shifts.

Embrace Continuous Learning

Consistent exposure and practice will lead to improvement. Remember, mastering the scribe role is a process, and it’s okay not to have everything perfect from the start. Keep practicing, ask for feedback, and adapt your strategies as needed. Over time, these efforts will enhance your efficiency and confidence in managing medical records.

5. Performance Evaluation & Monitoring Of Medical Scribes

The daily activity reports are delivered to the doctor at the end of the day to summarise the day’s charting activities. This report will provide the inputs for monitoring the activities and performance measurements. The scribe’s progress must be tracked and measured, and changes made as appropriate. It is vital to monitor and analyse the situation to ensure that you have the suitable scribe for the role in terms of personality and skill set and to make required adjustments.

The physician practice can evaluate the success of the medical scribe program by measuring critical indicators compared to the set goals. Examples of goals may include reductions in transcription/scribing costs, improvements in overall documentation, reduced turnaround time for authentication, and increased patient satisfaction. Organisations can analyse the benefits of a scribe program through standard metrics currently in use in the facility or practice. The metrics include, but may not be limited to,

The use of scribes contributes to at least a 15 percent revenue increase
It has improved patient satisfaction scores.
Changes in the number of patients seen after the scribe per hour or day,
Percent of clinical time versus administrative time,
Number of incomplete medical records,
Arrival to consultation complete time

These five tips are borne out of a decade of experience in virtual medical scribing. Not all methodologies make perfect for all. You need a particular kind of methodology for your practice. Use these tips to create a method for your practice to onboard and manage Medical scribes.

Why Do I Need A Medical Scribe ?

Hiring A Medical Scribe

What Skills Should A Medical Scribe Have?

Scribe Onboarding Protocol

Evaluation & Monitoring Of Medical Scribes