The Scribing Scripture

By Manali Patel & Evanie Anglade

Manali Patel is a former ED chief scribe at University Hospital located in Newark, NJ (fun fact: where ScribeAmerica CEO Michael Murphy completed his EM residency!). She is currently a Biology major with a minor in Philosophy and Applied Ethics at New Jersey Institute of Technology and wishes to pursue a career as a physician in the future. In her spare time, Manali enjoys scrapbooking, listening to music, spending time outdoors, and going for late night walks (especially on the beach)!

Evanie Anglade is a current ED scribe ambassador at University Hospital located in Newark, NJ. She graduated from the University of Pennsylvania in 2019 with a B.A. in Public Health. She intends to pursue medical school and further her epidemiological research interests in a Master’s of Public Health. In her free time, she enjoys rock climbing, running, and gardening.


Introduction

“Ask not what you can do for your provider, but what your provider could do for you” is something that I constantly kept in the back of my mind as I eagerly embarked on my journey as an Emergency Department (ED) scribe. Some of the primary reasons hospitals, outpatient facilities, and private practices employ scribes are to increase the quality and efficiency of patient care; decrease wait times, consequently improving patient satisfaction; and decrease physician burnout, especially at sites with high-patient volumes. However, you too can get your share of advantages from this position.

As a pre-health student, you face a lot of competition––against fellow medical scribe applicants and, further down the line, against others who are also interested in pursuing a career in the healthcare field. There are thousands of other pre-health students out there all trying to gain meaningful clinical experience that will enhance their applications. You may wonder, “How can I potentially stand out and make myself an indispensable asset to the healthcare team?” Simply put, it is all about being good at your job and utilizing all of the resources available to you in this clinical setting. Similar to the clownfish and sea anemone who have a mutualistic relationship in which both organisms provide benefit to each other, you and the provider can mutually benefit one another. As a scribe, you are there to alleviate some of the documentation burden, while the provider can, in turn, support your career development with advice and connections.

This article will discuss the practice of scribing and detail some of the benefits of this job role along with a few tips on how to capitalize on those benefits.

Clarifying Your Goals

It seems as though most people who find themselves scribing often have longer-term career goals in mind that do not necessarily involve scribing. Many medical scribes tend to be college students or recent graduates looking to pursue graduate healthcare programs, like medical, physician assistant, and nursing programs. With this in mind, it is important to develop a working list of goals that clearly delineates what you hope to accomplish while employed as a scribe. You should reflect upon this mental checklist every time you clock-in for a shift, as it will remind you of your intentions with this job, both professionally and personally.

A major goal that should be at the top of your list is to be good at what you were hired to do—scribe. Like any other job, scribing requires you to hone certain skills that help you perform your job well, which include completeness, accuracy, and efficiency. Self-evaluation before, during, and after your shift is necessary in order to continue making progress in your job role. This self-reflection may come in the form of reviewing your previously written notes from prior shifts and taking note of changes made by the provider. This will help you better tune into provider preferences and generally enhance your scribing abilities. In addition to self-analysis, you may also want to consider directly asking providers for critiques on your work in order to learn exactly where your weaknesses lie. The providers will be happy to know that you are open to accommodating their unique preferences and are flexible and willing to learn.

Aside from professional goals, you should also include personal ones that you hope to accomplish while as a scribe. You may hope to learn the definitions of all the medical terminology you come across while on the job. You may hope to learn the ins and outs of ED flow. You may hope to build a rapport with a few healthcare professionals and potentially secure a letter of recommendation.

Clearly defining your goals upon starting your job will help you act intentionally during your shifts so you can reap the most benefit from your time as a scribe. Of course your goals may change over time as you garner more experience and learn more about the nature of your job, but having at least an idea about what you want from this experience will help you in the long-run.

Navigating the Workplace

As many scribes are college students or recent graduates, for some, this is their first work experience. With that comes a learning curve about how to not only effectively do your job, but also comport yourself in the workplace. Just as how you behave differently around your professors and advisors compared to your friends and family, you are also likely to behave differently around your coworkers and hireups.

The workplace tends to have a particular culture that new hires have to navigate and ultimately assimilate to in order to succeed in this new environment. This idea translates in the context of hospital workplace culture and scribing. In the workplace, there is an unspoken formality that employees are expected to abide by, and as an employee of a vendor to the hospital, which scribes often are, you are an extension of your company and are also expected to represent it well. This is important to keep in mind as you move through this new environment. The hospital workplace is typically imbued with an air of intensity and seriousness, as healthcare professionals may be providing lifesaving care in the patient room right across from your desk. To work in an environment such as this, you must be willing to match the earnestness. This may require you to hone skills that help you accurately “read the room.” Developing this skill set is essential to performing your job since from time to time, you may have to strike up a conversation with the provider, who is likely very preoccupied, to ask for clarification on perhaps the patient’s history of present illness (HPI) or physical exam findings. Knowing when to probe for information will help both you and the provider complete patient charts accurately and efficiently. For example, after monitoring the ED flow and the provider’s general demeanor, perhaps there was no right time to ask the provider for physical exam findings for a patient before the end of your shift. Instead of inappropriately interrupting the provider at some point during your shift, it would most likely be more helpful to simply make a note for the provider indicating that that particular patient chart still needs physical exam findings. Of course, the way in which you “read the room” is decided on a case-by-case basis as every situation is unique and every provider has his or her own preference.

Additionally, just as most jobs come with an emotional burden, so does scribing. There are various sources of emotional labor that can affect your ability to effectively perform your job. While scribing, you may find yourself dealing with the emotional impact of a particular patient case because of its gravity and/or unfortunate outcome or because it personally resonates with you. You may also feel an emotional burden from the stress of your job. Maybe the provider is asking where a particular patient note is, not knowing you are currently three charts behind. Maybe you realized the provider changed the entire HPI in one of your notes, making you question your ability to scribe according to provider preference. These instances in which you are challenged may be emotionally cumbersome, but are a byproduct of being a medical scribe. These types of experiences may initially be uncomfortable but can help you discover coping mechanisms to operate in high-stress environments.

As a scribe, it is in your best interest to discover your “work personality” and how you can readily tap into it while on the job. Being asked to do your job thoroughly, accurately, and efficiently in an, often, intense, serious, and emotionally laborious environment is no easy task. This is why it is important to determine what mindset you need to adopt in order to complete your job successfully, yet not lose yourself. This new “personality” does not necessarily have to be so distinct from your natural personality. It may simply come as being sensible (e.g., knowing when to engage with the providers), considerate (e.g., letting the provider know when you step out for a break), and accommodating (e.g., asking the provider if there is anything else you can help with before clocking out of your shift or when you are all caught up with your charts). Of course, you should still be yourself and are welcome to enjoy moments of levity, but having this designated “work personality” may help you better remember the characteristics you should embody while working.

Active Learning

Unlike some other clinical experiences pre-health students may encounter, scribing requires active learning. Even though you go through weeks of classroom and clinical training to learn how to properly scribe, you can and should continue your learning while on the job, which requires participating with the learning process. When you start scribing, chances are that you will be extremely cautious and check your charts multiple times before you share them with your provider to review and sign off on. However, after a few months into the job, you will have mastered some skills, making aspects of your role easier and seemingly mundane to you. Chances are that you will not check for mistakes or critically think as often when this new sense of confidence sets in. In order to make the most out of your scribing experience, you will need to discover ways to actively learn while on the job.

Some people essentially describe scribing as “shadowing on steroids” since you have responsibilities, which actually impact the quality and efficiency of the patient care. There are things you can do to interact with the learning process while scribing. For example, you can look up medical terminology new to you after the provider dictates physical exam findings, EKG findings, or differential diagnoses. If you want to go a step further, you can do more research on some of these terms and ask members of the healthcare team a few meaningful questions about the concepts you learned about. Doing some research prior to engaging with the provider or other members of the healthcare team will show them that you are eager to learn more about the healthcare field and, ultimately, better serve you than simply blindly asking questions.

You can also actively learn when completing the assessment and plan portion of charting. This aspect of the patient chart is where you will include notes on the provider’s medical decision making (MDM). Understanding the provider’s thought process when he or she orders certain labs, imaging, and medication given the differential diagnoses for a particular case will allow you to better understand and document the provider’s MDM. To do this requires you to think like the provider, with the limited medical knowledge you possess, and actively learn, as you will be asking yourself questions about why certain decisions for the patient’s care are being made. Active engagement in the learning process will ultimately help you avoid charting errors and generally strengthen your documentation practices.

Over time, you will know exactly what to include in your notes when patients come in with certain conditions, how to properly phrase it to communicate your point, and develop a logical thought process that will allow other healthcare professionals opening your charts to follow your stream of thought and justify why the provider ordered such labs, X-rays, CT scans, and medications. Many scribes, even some that have been scribing for a few months, tend to struggle with phrasing and the flow of their HPI, as they tend to become caught up with the  format of the standard HPI taught in training and resist deviation from that method. However, if you take the initiative to thoughtfully consider why your physician is asking particular questions or making certain orders, you can significantly improve your understanding of various pathologies and charting skills.

Power of the Process

Scribing requires you to be an excellent writer and recordkeeper. While on the job you can improve your written communication skills, as you push yourself to think like a healthcare professional and write clearly and concisely. Once you become accustomed to the typical way of writing the HPI as taught in the scribing crash course, you will quickly notice that HPIs are not a one-size fits all. Although certain elements are essential in every HPI, each one has a unique narrative, as no two patients or patient encounters are alike.

Referring back to previous charts written by healthcare professionals may help you gain a better understanding of how to more effectively communicate through your writing. Of course, this does not mean clicking through patient charts that you are not documenting on, for that would be a HIPAA violation. Rather, as you navigate through the chart of a patient you are responsible to document for, you should look into the notes of previous hospital encounters written by other healthcare professionals. This will provide you with some inspiration about how to approach patient charting and using medical lingo.

Perhaps at first, dissecting an HPI written by another provider might seem time-consuming and daunting, if you do not understand some of the “doctor-speak.” This is where some homework comes in. Make a Google Document or even a notebook in which you write medical terms that are new to you, particular elements of someone else’s HPI that you like, or common phrases that are worded well by someone else. Jot these down and research the meanings of the terms you do not know. Later, you can expand on and refer back to your personal “cheatsheet” in order to write professional, clear, and concise charts.

Additionally, it is important to take note of the types of questions asked of the patient, abnormal physical exam findings made, and orders placed in order to gain a better insight into what providers look for when approaching certain complaints. Over time, you will notice that you will be the one asking the provider whether the patient had nystagmus for suspected PCP use or peripheral edema and cords in the extremities for a chief complaint of chest pain. The provider may realize he or she forgot to check and will follow up with a reexamination. Do not be surprised if the provider thanks you and praises your critical thinking skills and keen memory! Once you have mastered the skill of thinking like a provider, you might be the one interrogating your provider with these types of questions which will leave them appreciative of you, ultimately building a better relationship with them.

Ultimately, the notes that you write on behalf of your provider are not only read by the provider who will sign off on them, but they are also read by other healthcare professionals perhaps from different specialities who are taking over patient care. Thus, it is essential that you are able to communicate effectively and succinctly through your writing.

Finding Your Voice

Relatedly, another key facet of scribing is knowing how to be an effective oral communicator. This is important not only professionally, but also personally, in the sense of career development. As previously mentioned, knowing when to approach the provider to probe for further information about a patient encounter and when to provide updates on lab and imaging results are essential for both charting efficiency and adhering to provider preferences. Additionally, as the scribe, you serve as another pair of eyes whose attention to detail can help support quality and efficiency of patient care.

Because a patient’s chart is a living, breathing document, you are tasked with the responsibility of updating the information in the chart when new details of the patient history or additional physical exam findings arise, consults have taken place, or results have come in. To ensure clarity when making these updates, it is important to consult with the provider when appropriate. A general rule to follow is to alert the provider for matters that may directly impact patient care (e.g., if the provider forgot to order a medication) and waiting for a lull to speak with the provider for matters that are more charting related (e.g., when noting what was discussed during a consult). Ultimately, it is important to interact with the provider, depending on their preference and level of comfort with scribes, throughout your shift.

Based on your judgement, when you do ultimately engage with the provider, it is crucial to speak articulately to relay or receive the information needed, as the provider may need to quickly divert his or her attention away. With that being said, it is still important to speak to the provider as you would generally speak to other human beings––they are, in fact, not robots and also have feelings. It is normal to feel intimidated or feel as though you can only be austere or serious when interacting with providers. However, it is helpful to remember that they are also people who were once in a similar place as you. Once upon a time, these healthcare professionals were also eager pre-health students, so they will likely be able to offer you advice, ease your anxieties, and give you a sense of direction and motivation.

Speaking up, when appropriate, can also serve your career development because this is the way you build rapport with providers, which may result in a letter of recommendation. Once you have mastered the art of scribing, you will become more efficient at your job, giving you more time to foster relationships with the providers. The better they know your character and you as a person, the more likely they will trust your charting abilities. Earning the trust of those you work with will make scribing more fun and help you stand out as a “superscribe,” ultimately distinguishing you from your peers. This can positively impact your professional future in healthcare, in terms of graduate programs and climbing the corporate ladder within your company.

There will be people in this work environment who you may not know well but are rooting for you on your professional healthcare journey. Sometimes members of the healthcare team will specifically encourage you to ask any questions you may have about this particular career path. And sometimes these people were once scribes themselves! So, yes. You are allowed and should feel inclined to smile or laugh at a joke, listen in on stories being shared with the team, and comment or offer insight on certain situations you can speak to. Even though a vendor, as the scribe, you are also a part of the team.

Medicine Through a Social Lens

Not only can you learn an invaluable amount of medical terminology and observe the day-to-day life of healthcare professionals, but you also get to be an integral part of the healthcare team. You have a remarkable opportunity to immerse yourself in your surroundings. Depending on the location and your specific site, you may hear fascinating life stories of patients, whether it may be the struggles they have faced with mental health or obstacles they have overcome while dealing with addiction. You may get to encounter individuals that are victims of healthcare disparities and other social inequities. You get to see medicine at its rawest and realest form. By exposing yourself to a diverse patient population, one that includes individuals from underserved communities, different cultures and races, and varying socioeconomic classes, you are given the chance to build both your structural and cultural competencies.

Simply put, you see a world out there that might be completely different from your own. You get a firsthand account of “real-world” medicine distinct from the glamourous narrative portrayed on television. You will see that healthcare can, in fact, be riddled with long wait times, high-patient volumes, social inequities, patients unfairly plagued with preventable chronic illnesses, and concerned loved ones. Additionally, you get to see and hear how healthcare professionals respond to and manage this dynamic environment with the careful language used to talk to patients and to minimize stigma.

From seeing victims of domestic abuse, to trauma patients severely injured in car accidents, to worried young adults requesting STD testing, to concerned uninsured patients requesting prescription refills, and to housing insecure members of the community who present to the ED simply in need of a place to sleep, you see it all. As a scribe, you will witness the power of healthcare and both its benefits and pitfalls.

Conclusion

On this job, you will see the cardiac arrests, the drug overdoses, the “arrivals to trauma,” and all of the collaboration, expertise, years of training, and rushing adrenaline at play just to save a single life. While you still will not be medically qualified to save another person’s life by the end of your scribing career, you may be able to save at least one person’s life––and that is your own. In this role, you will be exposed to different facets that make up the reality of medicine. This is a remarkable experience to immerse yourself in the real world to truly determine whether or not a career in healthcare is a life you want to pursue before making the decision to commit a lifetime to it.