The Life of a Medical Scribe
November 9, 2016
Are you a student who is interested in becoming a doctor or a physician assistant? For many medical and PA schools, relevant experience is a key factor in the application process.
Whether you are shadowing, volunteering, or working in a hospital or clinic, admissions committees are looking for applicants who know first-hand what it’s like to work in the field. For some medical school hopefuls, working as a medical scribe is a great way to gain this experience — in fact, a spokesman for PhysAssist Scribes described it as, “the best clinical hours and experience you can get.”
Like many hospital jobs, scribing can be taxing, requiring long hours, graveyard shifts, and high levels of energy and focus; however, if you think you can handle it, it can be very beneficial and rewarding. Here are some tips and tricks for working as a medical scribe as told by Aaron, a 23-year-old emergency department scribe with PhysAssist:
It is important to show up to every shift 15 minutes early. I did so today on my 9am – 6pm shift in order to prepare myself adequately, making sure to study my physician’s preferences on our database as well as log-in to the charting system.
I grab a piece of paper, crucial to maintaining what we call the active patient list (AKA a scribe’s best friend). The physician arrives, and we are ready to see our first patient. I write the patient’s name, chief complaint, and room number on my sheet to start the tally.
From that point on, the role of a scribe is very straightforward. I follow the doctor to every subsequent room whether it be to obtain the HPI (history of present illness) for a new patient or to document procedures and/or re-checks that were performed. Every patient needs a physical exam charted and a few other necessities in order to create a “full” chart.
So, you and the doctor see the first patient, and you begin typing at a blistering pace (maybe not that fast, but it is important to move quickly as to not get behind). Once the physician has ceased his questioning, you return to your station and the physician relays physical findings to you, which you proceed to input into the charting system.
The doctor puts in orders for the patient (labs, medication, radiology, etc.) and you move on to the next one. This pattern repeats until the physician has reached around eight patients or so, an amount that is manageable simultaneously. At this point, lab and radiology results have most likely been completed for viewing.
The scribe will then review the labs and copy and paste the X-ray or CT interpretation given by the radiologist. The physician then comes to a decision as to the fate of the patient: discharge back home or admit to the hospital. Most simply stated, this depends on the severity of the patient’s condition.
The scribe oftentimes will provide the reasoning behind the doctor’s plan and then chart the diagnosis and disposition (discharge, admit, or transfer), making sure to give the patient relevant instructions if they are being discharged or document other specialties that were consulted for admission.
Old patients are replaced with new patients, and so on, until an hour or so before your scheduled finish—this allows for the physician to wrap up their work. You then leave with a wealth of new medical knowledge that you continue to build upon with each shift.
Just a couple tips for those considering this rewarding position: things move quickly depending on how busy the ER is that day so it is important to chart as fast as possible. One must be very attentive and diligent, though, ultimately making sure that all documentation is accurate.
Expect irregularity: early morning shifts, graveyard shifts, nine hour shifts, twelve hour shifts, weekends, weekdays, etc. Almost every week is different so don’t waste your time dreaming of a Monday through Friday 9 to 5 job. I mean, you constantly check the schedule just to make sure you don’t miss a shift. The ironic reality of scribing, however, is that no day is very typical.
Today, for instance, was pretty average in pace—beginning with a rush of patients but ending fairly dead. You just never really know what to expect from the emergency department.
Are you a medical scribe? Tell us about your experience! And be sure to check out our job listings to see who is hiring in your area!