When you begin working as a medical scribe, it can be rather intimidating. You are entering a clinical environment where you are unsure of what you will see or how you will react. A common fear is asking a “stupid question,” typing a medical term incorrectly, or not being to locate a word that the provider said in their dictation on Google. Who knew postprandially was even a word?
Those fears quickly subside when all of those questions and concerns are addressed with enthusiasm by the providers who have the opportunity to teach and share their medical expertise. In no time, providers are quizzing their scribes on how they will order for a specific patient. As a scribe, you’re an essential part of the team and you’ll quickly feel valued by providers and your fellow scribes. For most pre-health students or graduates, this is the first time they’ve ever truly been incorporated in the medical team in a clinical setting.
Taking Your Education into the Real World
Walking into the Emergency Department after school or another job, or maybe just a Netflix marathon, never feels like going to work. It feels like you are entering a place where you can put your pre-health education to practical use.
Your shift begins by letting the provider know that you are working with them, and then some chart review before you begin seeing patients. In the patient room you rapidly type shorthand notes of what the patient claims to be ailing them and then create a short, yet succinct summary, of their tale. You’re also responsible for entering laboratory and imaging results as they come in during the patient’s visit and then speak with the provider to determine the disposition of the patient – are they sick enough to warrant a hospital admission or can they be managed as an outpatient?
Next, you’re given a dictation that details the medical decision making for the patient from the provider. This outlines what the provider did, how they came to their diagnosis, and what their plan of care will be for the patient. In the Emergency Department, you will see everything from a sore throat or earache to ruptured abdominal aortic aneurysm or intracranial hemorrhage; you must be prepared for everything.
You’re Not Just Taking Notes
Although medical scribes are not directly caring for patients, they are responsible for telling their stories. Whether the story is a sad, happy, confusing, or strange, it is our job as scribes to accurately document the visit. Scribes not only aide in provider efficiency, but they also give providers a chance to do what they love the most – teach future generations of medical professionals.
Practicing medicine takes a lot of brains, but it takes even more heart and scribes have the opportunity to see the full spectrum of patient care and learn something new every shift.
By: Kassandra Remmel
St. Cloud State University Graduate
EPPA Lead Scribe 2014– Present