06 June 2007

Ars Scribendi

I would be interested to hear whether any ED docs out there have used scribes in their practices.

Our group is always looking to improve efficiency, and there are a number of folks who are downright evangelical about using scribes. They certainly sound good, but I take that information with a grain of salt, coming as it does from the true believers.

So I would be interested to hear from a more unbiased (or at least disinterested) audience. Do you or have you used scribes in your ED practice? How do you use them? What sort of things do you have them doing? (other than just, you know, writing.) Where did you recruit them and what sort of training (if any) did you give them prior to starting? What were the common pay scales?

And of course, most importantly, how do you view the experience? Did it impact productivity in a positive way? How did the doctors like it? I think some of our docs are uneasy about the notion of having a "personal assistant;" others are downright salivating at the prospect.

We will be looking at the concept over the next couple of months. If you have experience, please have at it in the comments (or over email).

Thanks.

8 comments:

  1. How does having a scribe affect liability should faulty data be even possibly connected to a negative result?

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  2. Scribes are a great opportunity for the Scribes but they also provide a great opportunity for errors. Here is the problem, it encourages Physicians in the ER to continue to use Verbal Orders which are very error prone. Verbal orders in ER’s are not allowed by most institutions (although widely ignored) and JCAHO except in Code type emergencies. Most astute Nurses (at least in facilities with good job protections for nurses) refuse to accept them if they are not delivered with the written order. It allows Physicians to maintain their bad habits of poor written communication by having a scribe write things out for them. Even if they sign there is opportunity for error because busy people tend not to read in detail what is presented to them to sign. I as a Nurse do not want an intermediary (scribe) in the loop when receiving patient orders. I suspect the ED Attendings who get the scribes love someone following them around attending to their needs. Some of the other duties of the scribe are very valuable such as organizing the labs, old records, and other info needed to make decisions. What role would the scribe have in a EMR COE system. Isn’t the reason for the person giving the order being the one who enters it to reduce errors?

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  3. these comments are just "what if's" from habitual worry warts. I worked in group who used scribes for years. It was liked by all, made the group much more productive and also made the nurses more productive. They were sr nursing students, triage nurses and other rn staff that had interest in learning. They didn't just write chart. The wrote for some and not others. It was up the the individual doctor. What they did was go chase labs, talk to patients about updates in process, allow immediate pelvic exams without waiting for another chaperone (read busy nurse). They could get meds and give them in most instances as they were RN's. The had more understanding about the patients care and could help educate them, they did quick discharges to turn over rooms. They chased down xrays, made phone call to track consultants down, they fielded patient and pharmacy calls and requested records. Sound a lot like what unit clerks and nurses do mostly, eh? Well in the age of cut backs they help make the department run. After the hospital pulled the plug on the scribes, some of the guys hired their own. But the group went to mid level's and well, you know. All the hand wringers set around and wondered where our effieciency went and the nurses quit in droves as they were expected to work like slaves with too much to do. Like the song goes, you don't know what you got until it's gone. I was in a level 1 trauma center with 4-5 EP's on at a time and only the best rn's in the department were scribes. They rotated and every single one of them felt it made them a better team player with the other physicians, and helped them understand a large part of patient care and the process. I wasn't aware of any loosers in the scribe program. Political speak would be a win win situation. But I've never met a hospital administrator who would let a sucessful program alone if he could save a dollar to hire a new marketing manager. Sorry for the cynicism, but, the program was one of the highlights of my years in practice. Good luck.

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  4. What are the credentials doctors are seeking from scribes? How do doctors ensure that they (the scribes) are properly transcribing the prescriptions so there aren't mispellings?

    Medical transcriptionists frequently get extensive training. Are these the folks who are being scribes?

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  5. We nurses automatically "scribe" for each other and for the doctors during a code or during some other high-intensity situation like an acute MI, and that works just fine. In fact, the nursing supervisor of the hospital comes down to scribe/record for codes.

    Anonymous' comment makes me think of the whole "Handmaiden of the Physician" concept or what we call an ER "float nurse" who also has to write stuff down for doctors.

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  6. Matt,

    I don't know much about medical malpractice, but assuming you were actually able to get a case in front of a jury, I would imagine plaintiff's attorneys would explore the scribe angle.

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  7. Where I used to work we had scribes. In the ED they were a must for some reason. But I mostly refused their services because everything went slower and there were many, many misspelled words. In the end I did most of the job anyhow because I just did not sign the mess. Hope it works out good for you. Would be glad to read about it...

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  8. I have worked at several hospitals without scribes, and would never work at one without them if possible. I came to my present facility a few years ago and quickly came to value scribes. When the director stepped down earlier this year, I stepped up.
    Scribes are a useful way to connect with your patients more effectively. Let me explain: Imagine that almost all your busy work was done for you (writing the chart, entering orders, pulling up x-rays, recording results of labs and other tests, documenting all your rechecks, reminding you about critical care, pulling up past medical records, checking to make sure labs are being done, paging and re-paging consultants, etc...). How much more time do you think you could spend interacting with your patients and seeing more patients?
    In our scribe program, we use motivated pre-med students from a local college and rigorously train them in the busy-work that we were all thrown into on our first day of residency/post-residency without any specific training. We are very selective and pay a very modest salary ($9-$15 depending on experience). The scribes get an unparalleled clinical experience either cementing medicine as a career path or excluding it. They also get a far greater opportunity to get into medical school as we mentor them on techniques to increase their chances. Last year we helped 7 scribes move on to medical school - only nine people from the local college got into med school. We loose about one scribe per two years to changing career choices and have approx 30 scribes.
    Scribes also help us successfully implement patient satisfaction pathways that are having a noticeable impact on our dreaded post-ED surveys. In addition, we are in the process of implementing a research program at our community hospital that has loose academic ties that will allow our 60-70k/year hospital to publish research as well as help us look at our processes from a rigorous, statistical standpoint.
    There have been some runs in with the nurses as they seem to feel that doctors shouldn't maximize their time. There is some resentment that we actually have someone that will actually always do what we ask... Fortunately, we can address their concerns quickly and maintain our program despite the occasional malcontent.
    Regarding the occasional mix-up in spelling, etc, the improved legibility and completeness of the charts far outweigh any perceived liability. If anything, they will protect you from the "if not documented, not done" problem because everything is documented!

    I obviously could go on, but felt it was important to counter the negative comments.

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