With EHR systems on the rise, the need for medical scribes has rocketed to an all time high. While some providers feel comfortable documenting their own medical encounters, the majority have incorporated medical scribes to document while they tend to patients, allowing for more face time. This rise in demand has left practices scrambling to acquire or train more scribes. Yet another element of difficulty, in the current healthcare landscape, is that many practices are also still struggling with staffing issues as a result of furloughs brought on by COVID-19. Training and promoting in-house seems like the clear solution, but it is often a difficult task due to the amount of time required to train each individual, as well as the lack of organization and consistency behind the training.
Organizing Clinical Findings
One of the more challenging concepts for new scribes is the organization of the clinical findings. In the majority of EHR platforms, the common structure entails searching for findings within a specific section or subsection defined by the specialty. For example, ophthalmology-specific platforms have a distinction of Anterior and Posterior Segments and subsections which may include: Adnexa, Lids, Conjunctiva, Sclera, Anterior Chamber, Iris, Lens, Vitreous, Vessels, Macula and Periphery. If the scribe-in-training is unfamiliar with the eye structures, this can be an overwhelming and intimidating list to sort through.
Whatever the specialty may be, the best practice is to build defaults in the EHR system to allow for quick selection of most common findings. Whether these defaults are a dropdown menu of common findings, diagnosis specific defaults or normal defaults with a quick shortcut to replace them with abnormal findings, they can aid scribes in documenting efficiently without feeling paralyzed mid-exam. The goal is to minimize free texting or searching for common findings.
Building an Impression and Plan
While documenting exam findings is an important portion of the chart note, building an impression and plan are integral parts in the assessment, recommendation and coding components. Like adding exam defaults, the most efficient way to tackle the impression and plan sections is to build common phrases or quick text options for the most frequently seen diagnoses within that specialty. The most precise method to narrow this down is pulling reports from the practice management system to include the top twenty diagnoses attached to claims. This should provide great insight as to what type of diagnoses are most popular for the practice or provider. A well-composed impression and plan consists of identifying the diagnosis, including the physician’s recommendations, and then a course of action with any urgent symptoms associated to the patient’s condition.
Follow-Up Notes & Orders
Prior to signing off on a chart, the scribe should also include follow-up notes that include any anticipated diagnostics or procedures for return visits. This follow-up note should be detailed enough so that it can serve as both insurance preauthorization documentation and workup instructions for technicians in the subsequent visits. Creating shortcut methods within the EHR system to document most common follow-up exam types, diagnostics, procedures and schedule intervals are key to efficiency.
Documenting patient encounters can be a cumbersome and overwhelming task for both physicians and scribes if their EHR systems are not optimized. Creating a more structured and standardized method of documentation will not only facilitate training for new scribes but will also result in an efficient clinic workflow.
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