Scribes in the ED

Movin’ Meat asks for input about scribes in the ED. Since I’ve had the benefit of scribes for every shift the last 4 years, I have some information and perspective to share.

Frankly I love our scribes, and there are a number of benefits for the docs:

  • legible charts done contemporaneously during the visit (and finished with the encounter)
  • orders ready to go when we walk out of the room (requires familiarity with style)
  • smart young people who are motivated and want to learn
  • another set of eyes and hands getting labs, xray /CT’s / sonos on the chart (the right chart)
  • smart ‘gofer’ for phone calls, etc
  • Can push you to see another patient (good, though you might think otherwise)
  • can slow you down if you let them (requires some people management)
  • did I say legible charts? Bonus!
  • Quicker transition between new patients

I should say a word about the scribes: they’re the hotrods from several of the local Universities, usually the pre-med types, and handpicked by the Doc who runs the program. Though I have no actual knowledge of the procedure, he’s got it down, as very few drop out or unsuitable for the job. They don’t come for the pay, they come to see if medicine is something they want to do, and for a modest paycheck.

Oh, and they’re very very sharp. They have a steep learning curve initially; the new vocabulary of medicine needs to be mastered while physically in motion, and the arcana of what chart goes where to get orders, procedures, etc. done while busy (the ED doesn’t stop to make learning their job easier). There are now, in all the Universities here, groups of students who work as scribes, so it’s not hard to recruit new ones (I’m told) when it’s training time.

We’re doing training now, in preparation for our current scribe Graduates getting on with their lives (Fair Winds and Following Seas)! Several are off to med school, some are off to PA school, one is going to Law School (!), and some are going to get Masters/post-bacs (usually those med school bound who didn’t get in this year). A few decide medicine isn’t for them during this, and go another direction (and that’s a huge benefit to them, not a loss, as now they haven’t made a 200K mistake). This scribe program has been in existence long enough some of the prior scribes are back as fully-trained Emergency Physicians (the circle of scribedom, I suppose), and there’s definitely a sense of continuity within the scribes.

Apparently there was a lot of medical staff resistance to allowing scribes in the ED (I’m not sure why), but it has resulted in the following rules, still in force today (and I’ve heard from another program that lets them do the ROS independently):

  • Scribes are there to collect information obtained by the doc, not to ask questions on their own (the scribe cannot take ROS or HPI independently, etc)
  • Not allowed to touch patients (not licensed or trained for that, though they do get all the healthcare shots)

Without making too big a deal about it, there are a few problems, but they’re workable:

  • Nurses don’t like being asked questions by the scribes, generally, though we have an outstanding nursing staff and terrific nursing leadership, so that’s not a big problem here (your mileage may vary, different at different hospitals)
  • Your chart is your chart, no matter who is writing on it, so checking it is essential
  • there’s nothing wrong with taking the chart and writing on it (but this makes some of the scribes uncomfortable; like asking for help as an Intern, it’s seen as a sign of weakness, and I’ve ruffled a feather or two doing it)
  • Not every scribe is equal. Oh, you’ll love them equally like your kids, but there will always be the ones you can work with and those you’re happy to see show up for your shift (and they feel the same way). (Probably).

Our scribe program routinely sends experienced scribes on what I call ‘missions’, to take the Tao of the Scribe elsewhere, teach a cadre of local people about scribing, and hand them off a turn-key product. I wouldn’t do it that way, but it’s not my program. They do it frequently, and the experienced scribes like the travel, change of scenery, and the experience.

To summarize: a lot of upside, not a lot of downside (cost isn’t that much given the usual population used) and once you try it you won’t want to go back.

Our program’s Official Website (horrible colors but good information).


Comments

  1. It’s nice to see you write so kindly of us. I worked for 2 years, and absolutely loved it. I would trade my current research job for it in a heartbeat. I think you nailed the scribe down to the “t.”

  2. Kyle, you’d be welcomed back with open arms.

  3. Heh. They should hire you to redo the website for them, you summarize it nicely.
    I loved the job too and I always enjoyed working with you.
    Although the paycheck was ‘modest’ I’m only making a couple bucks an hour more now (if you calculate for the overtime I would’ve racked up).
    Tom (former scribe turned ER intern)

  4. not being familiar with the scribe system, tell me…these people are like your shadow all day long and do your whole chart for you? Is there one per doc in the ED?

    wow…how nice that would be!

  5. EDres yes one per doc for the entire shift. Sounds crazy until you try it, then you never want to go without them.

    Tom, hope things are going well for you.

  6. Bad Shift says:

    I’m too OCD about my charts. By the time I got done checking to make sure everything was the way I wanted it, I probably could have dictated the whole thing anyway. But I’ve never worked with scribes so I guess I don’t know for sure.

  7. Wow, I would have killed to have this job when I was pre-med. I’m impressed that they are equipped with enough of the language of medicine to function efficiently as scribes – do you ever run into situations where they just aren’t following what you are dictating? I did kind of similar work for some endocrinologists when I was in college and was pretty comfortable with that area, but emergency medicine is much broader and I would think you’d almost need to be in med school to keep up with it.

  8. As a current scribe who will be starting med school this fall…

    Bad Shift-
    I think that you do have to give up a little bit of the OCDness to work with a scribe (especially with newer scribes). Everyone has their idiosyncracies, but I believe that usually you don’t lose any of the accuracy. Also, as you become more comfortable with your scribes and their charting proficiency, your speed can only increase.

    M-
    Yeah, it’s awesome. It’s much of the reason I went to college where I did; an excellent opportunity and a great symbiotic relationship when you and your doctors get comfortable. We do fairly extensive training lasting around 3 weeks that takes scribes through the gamut of medical lingo (including abbreviations and drugs), and it’s pretty rare when there isn’t a word that we don’t know. Also, you can always rely on your doctor if there are words or concepts that you don’t understand, and that is where the opportunity for teaching really blossoms. And med school is eventually where most of us want to end up, so it’s a great head start.

    EJ

    P.S. The ‘Tao of the Scribe’ has another website; this one more tailored to those looking into scribe programs of their own: http://www.medicalscribeconsultants.com/
    Again, horrible colors, and I’m pretty sure it’s the only time that I’ve seen Trotter in a lab coat…

  9. i’m still in shock. do you know how much more productive i could be if i didn’t have to go back to my computer every 15 minutes to add something to someone’s chart, or NOT pick up that next patient b/c I’m so far behind that I’ll never leave from my shift if I don’t do some paperwork???

    SOOOO jealous.

    i guess when I go into academics, I’ll have the residents “scribe” for me ;-)

  10. jrobatc says:

    Are any of your current partners former scribes? I’m thinking particularly of a female MD who was a fellow resident at Trenchy’s Mecca. The program and your location line up with who I’m thinking of.

  11. JR,
    Without naming names, yes, one of Trenchy’s former residents is in our Big Group. The Big Group covers a lot of docs, most of who work at only one hospital, so our orbits cross only occasionally.

    Interesting how many of the scribes read this…

  12. I have to ask: why would nurses not want to answer questions from the scribes? We answer questions from everyone else, including the docs!

    With MY chart compulsion, I would have made a great scribe – good thing I didn’t know about that before nursing! : )

  13. Scribes are a great opportunity for the scribes but they also provide a great opportunity for errors. Here is the problem, it allows Physicians in the ER to continue to use verbal orders which are very error prone. Verbal orders are not allowed by most institutions and JCAHO except in Code type emergencies and most astute Nurses refuse to accecpt them if they are not delivered with a 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 if there is opportunity for error because busy people tend not to read in detail what is presented to them to sign. 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.

  14. When do the nurses get scribes? Oh yeah when hell freezes over…

  15. Thanks! :D

  16. There’s no reasons (other than cost) nurses couldn’t have scribes. I’ve often said they could use them.

  17. ERMurse, I don’t get it. The ‘verbal order’ you’re denigrating is written out (in much better handwriting than mine) by a scribe prior to it being done, thereby making it a written order, the holy grail of orders.

    The ‘continuing their habit of poor written communication’ is a non-sequitor given that the scribes are there to facilitate written orders.

    So, no.

  18. We have computerized charting and some of the docs want scribes to click the buttons on the order sets for them and type for them as well. How pompous is that?

    There are 4 chairs in the nurses station for 2 aides, 3 nurses, 1 or 2 med students, and 1 or 2 docs. No scribes, thanks.

  19. Two questions come to mind:
    1) In the long run, will there be an issue of whether these scribes are being sufficiently compensated, the flipside being, are you (not you personally) taking advantage of these people?

    2) Here is a more serious problem, perhaps not likely, yet like some unlikely medical conditions which could be catastrophic: Let’s imagine that a well-intentioned or not-so-well-intentioned scribe decides to write an exposé (or horrors, blogs) about what they have seen, heard while they’re scribing away.
    I’m sure the short answer has to do with intensive counseling of these people about HIPPAA, making them sign some sort of legal document or such, but how much protection is that? These are not hospital volunteers in and out of a situation, this is like having a journalist (sic) tagging along with you.
    And the related: What if there is some legal action? Can these scribes be subpoenaed to testify in a deposition about what they saw and heard? From what you’re saying, they see and hear a lot.

    I hope someone has thought of these and perhaps other worst-case scenarios.

  20. One example of pomposity is deciding what someone else should or shouldn’t have without considering their needs. Our parent corporation is rolling out EHR’s, and it’s made each EM doc between 30 and 40% slower; using scribes has gotten some of that lost speed / efficiency back. Docs are there to practice medicine, not feed a computer, and anything that gets the docs to the bedside and keeps them there longer (rather than staring at a computer screen) is a win.

    Docs are also one of the best examples of people who are slow to change / adopt new technologies, and scribes are young and nearly universally technically savvy, able to make the computers do things the docs couldn’t.

    Compensation is what it is. Some quit to take jobs that pay better. Nobody becomes a scribe to make money, they do it for the experience.

  21. I’ve been an ER nurse for a year and a half, and we’ve had scribes since I started working there. I love our scribes personally. They keep the doc organized, and more available to me (the RN) if I need med orders or what not. Plus if the doc is on the phone, or in a room with a pt, I can leave a message with his scribe (although it is incumbent upon me to follow up on said message). Also- with a really good scribe, I can say, “Hey, Jane Scribe, when Dr. Spreadtoothin gets off the phone, will you bug him to write orders for bed 12 so I can get her upstairs?” And like magic, 10 minutes later, I have admit orders. If the communication is good in the ER, it all flows like butttah :) Greg P raises an interesting point about legal matters though, and I admit it makes me curious about whether or not scribes can be subpoenaed or whatever legal term is applicable.

  22. Grunt doc didnt get it. The written order from the scribe delivered to the Nurse is a verbal order that is received by a scribe and transcribed into a written order and delivered to a third party, the Nurse. So from my point of view as a Nurse rather than one point of potential error (reading the MD’s writing) I now have the potential of 2.
    1. The scribe mis interperts the verbal order from the Physician
    2. The scribe selects (for EMR) the wrong order
    The main reason for CPOE in EMR’s is to eliminate steps (points of error) between the originator of an order and the receiver. Scribes adds steps.

  23. Computers have been in common use in homes and businesses since the mid 1980s. Why is it such a big deal in 2007 to ask a physician to at least TRY to use a new computer program before demanding new employees be hired? I’m the second-youngest nurse in my department, and most nurses are my mother’s age and not exactly tech-savvy. However, a nurse who refused to use/learn the program due to unfamiliarity with computers would get fired from their job. It’s part of the job; it’s not an optional part of the job. We never learned electronic charting in school, but, as nurses and as physicians, you have to adapt to new advancements and your organization has to stand behind the doctors and provide them adequate support during the learning process. What if the scribe calls in sick? The doc has to know the program.

    Some were requesting meetings about scribes with medical directors on the Go-Live day without even attempting to practice and get better at the software. There was adequate time to practice, an entire year, in fact before the Go-Live date. When the nurses have to learn the 12-step process for instituting the Heparin protocol and the non-intuitive 4-step process to complete the MRI checklist and chart it in the right place and where to find the obscure flowsheet to document peak flows (and 60 more things like this) and the doctors just get to say “hire someone to do all this tedious stuff for me”, to me, it seems pompous. We have to spend sometimes a full 30 minutes or more entering medications on a single patient. We hate the tedious stuff too and it makes our jobs harder (and we rarely get additional staff), but that’s just how it is.

  24. Also, adding on to what ERMurse was saying, I’m not sure if there is a way on EMRs for a scribe to enter in all the orders and set them aside, so to speak, for the MD to review and sign before they become active orders. I would consider it a non-valid order if a MD told a scribe what he wanted and the scribe entered it all into the computer and hit the “sign orders” button on behalf of the physician, which activates them for us to do. The “sign orders” button is a legal signature from a physician. I would not do any of those orders until it was somehow confirmed that the physician intended to order those things. On paper charting, it’s easy. The orders are written by someone else and the doctor signs them. If I knew a pre-med student entered orders in and hit the “sign orders” button to activate them without the MD there to review the orders, I would legally not be able to do any of those orders. That would put my license at risk and it certainly wouldn’t seem much faster.

  25. Trenchdoc says:

    When has a nurse in ANY state EVER lost their license for ANY problem related to a physician order?

  26. I would like to know from docs who have scribes – does it increase your efficiency? Are the patients seen quicker and moved through the ER faster? We have scribes at our ER and things don’t seem to go any faster….

  27. Hi Trenchdoc!

    I’m just saying the whole concept of EMRs and scribes is a license issue, at least how ours is set up. In our hospital, RNs have gotten in trouble with the hospital and with the board for letting LPNs take telephone orders from physicians [big-time no-no] or even nurse-to-nurse report over the phone, so it does happen. I dont’ think anyone ever got their license taken away, but a disciplinary action by the Board would follow you to your death.

    If RNs were knowingly completing orders entered by a scribe and not reviewed by a physician (or, even worse, if the scribe was entering orders in under the physician’s log-in), both the MD and the RN could have problems.

    Part of my pomposity argument is that MDs in our hospital have far fewer patients than in other parts of the country. 1 doc will have a max of 5-6 critical patients (chest pain, stroke, SOBs–we dont’ get Level 1 traumas) or 7-8 or so non-critical patients like belly pains and whatever else and that’s when the whole joint is full+ a hallway patient or two. I’ve heard in some facilities that MDs will have up to 25 patients each; in that situation, scribes or whatever would be essential. One of the doctors who routinely whines about the EMR and needing scribes spends at least 2 hrs per shift in the Doctor’s lounge or playing solitaire, and that’s on a busy day. We’re lucky if we can find him to tell him there’s a new patient.

  28. Nurse Kelly,
    I’m sorry your facility bought an EMR that obviously is poorly thought out and very labor intensive. That doesn’t make a doc’s subcontracting with a Scribe service (not hospital employees) “pompous”, it makes them better time managers. And frankly it’s their job to decide if they want / need them, not yours. The service is paid for (all of them I’ve heard about) based on number of hours used, directly by the doc. It’s the doc’s money, not yours, or the hospitals’.

    And your comment about scribes entering orders on EMR’s is a classic example of nursing resistance that has to be overcome for a Scribe to be useful. The same name goes on the bottom of the chart, the doc’s, whether it’s put on paper or clicked on a screen. Same process, same deal.

  29. Well, I guess I misunderstood—I thought the hospital hired them. Our docs were asking the hospital administrators to hire them scribes as a position paid for by the hospital. One wanted a scribe specifically because he’d never learned to type and didn’t think he should have to learn to type in order to chart. He thought the hospital should hire him one for that reason. “I was told in medical school that it was useless to learn to type because we’d be dictating our notes, so I never learned to type” was what he said specifically to me. I guess we’re talking about two different things.

  30. Note to Trench Doc and others not aware Nursings roles and responsibilities. Yes, Nurses have had license actions and many have lost jobs related to issues with orders and some that I am aware of have lost their license. Probably the next most common cause of action after issues with controlled substances. A Nurse cannot use in their defense (at least in California) that they were just following orders if the order was not valid or not in the best interest of the patient. The license is what makes the difference between a tech (or scribe) and a Nurse. We are not there to blindly follow your orders, especially if written and delivered by a non-licensed 3rd party. The Nurse is obligated by the Nurse Practice act to question the order or refuse to carry it out if not in the best interest of the patient.

  31. GD,

    You have probably answered this before, but what charting system do you use? Do you do dictation?

    In the past I just dismissed any discussion of having a scribe. But thinking about it today while I was running from code to code situations while my other patients that aren’t sick enough to register on the radar dectector languish for hours.

    The good nurses used to come up with the patients chart and say: “Here are the test results, the meds are given, the patients condition is X, and what is the next step to get the patient out of here?: Those nurses don’t exist any more. Those that do, we love you. The new breed of nurses are union employees, are assigned a ratio of beds, and are perfectly happy to ignore a patient to keep it full so they don’t get a new patient with new work.

    So yes, I want a scribe?

  32. GD,

    thanks for the detailed response, and thanks to all who chimed in. I agree with you, GD, that from a time management perpective it does not make sense to pay a doc $150/hr (or whatever) to be a data-entry tech, whether the data is being entered into a paper or electronic record. Ths gofer aspect of the scribe makes sense, too.

    I think that with our EMR (IBEX) it is not too onerous for the docs to order their own meds, so that can obviate the whole “is it a legitimate order” question. it’s really the documentation of the medical encounter that seems to pack the most bang for the buck.

    I’ll let you know whether we decide to proceed, and if so, how it goes.

    Cheers,

    SF

  33. We use a 3-copy NCR form that’s 8.5 x 14, and is used for all encounters (where I work most of the time), and T-sheets at a few of the other places (my part-time gig).

    I have no idea which they prefer. Perhaps they’ll chime in here.

  34. FYI–Every order, whether it be a med or not, is considered invalid to a nurse and to HIPAA for the purposes of charging unless a doctor has “signed” them electronically or otherwise. And it’s illegal for anyone but an RN to take a verbal order (a scribe can’t legally take a verbal order and sign it as a verbal order unless they’re an RN). For instance, if I’m standing next to a scribe, and the doctor says “place saline lock” at both of us, I can enter and sign the order as a verbal order and do it. The scribe can write down “place saline lock” in the computer but not sign it as a verbal order, rendering it inactive until the doctor logs on and signs it. Besides validity issues, there are charging issues…if something is not expressly ordered by a physician, we can’t legally charge for it. I, as a nurse, can start the IV and run a bag of NS in the ER without anyone telling me to do it, but if the doc doesn’t officially order it later, the hospital doesn’t get paid for the NS nor the placement of the IV.

    So with EMRs, the orders would have to be hand-written by the scribe (so he could remember what was ordered) then electronically entered into the EMR by the scribe and somehow the physician would have to log on, review the orders, and sign them ALL electronically. Sounds like far too many extra steps. Also, the Epic EMR has lab results and things right there on the screen with everything else, so there’s no need to run around to find paper copies of results. A nurse should be making sure labs/test results are coming back; this “they don’t do that anymore” stuff is BS and rude. We love to move product just as much as anyone. The lobby isn’t getting any emptier.

    Our EMR isn’t bad—ER Docs who are familiar with the program spend very little time entering/signing orders on the typical patient, perhaps 5 minutes or less. As I said, in complicated situations like codes, the nursing supervisor comes down to record/scribe. We still hand-write charting for codes and scan it in to the computer chart.

  35. Nurse Kelly,
    For someone who says they don’t work with scribes you’re awfully opinionated about what they can and can’t do. Those of us who actually do use scribes are very much more sanguine about their use, use them for their EMR’s, and it’s not a big deal, written or typed. I guess you think that the scribe is some independent actor making their own decisions, and that couldn’t be further from the truth: they’re there solely to help the doc get their records / orders onto the chart / into the system in as timely and efficient a way as possible. Everything that’s done by the scribe is at the express direction of the doc; again, it’s the doc’s name at the bottom of the chart, so what’s on there is the doc’s responsibility.

    Again, thanks for pointing out the barriers thrown up to scribe implementation. Nearly always by nurses from what the scribes who come back from their missions tell me. By the way that ‘only five minutes’ magnified by the 36 patients I saw tonight would have been, what, ‘only’ three hours. Three hours spent typing instead of seeing patients. Nope, can’t have a scribe, might cause a theoretical problem, and those three hours I’d have spent in front of the screen, well, patients like to wait. Because it’s important the doctor be the one typing. Right?

  36. Not typing–signing. Any monkey/scribe/secretary/nurse/aide can type, but only an MD [or PA/NP] can sign (and an RN can sign orders as verbal orders that can be co-signed later). Do you log on, review the orders entered into the EMR by the scribe and sign them electronically yourself or does the scribe sign them electronically on your behalf? If it’s the latter, even if the signed orders are exactly what you wanted, no nurse should do a single thing on that order set because it’s not a legal order even if it’s what you wanted. If I know one thing, it’s how to not get my livelihood taken away from me by the Board of Nursing.

    I’m totally on your side for paper charting, overcrowded EDs and scribes. Sounds like it would help quite a bit. I just see no overall benefit to making a 1-step process a 4-step process with respect to EMRs.

    PS: Our doctors would all walk off the job if they were consistently seeing 36 patients per ?12 hours shift? The most prolific doc bragged to me that he saw “2.4 patients per hour” last month. I think we’re spoiled maybe. We have health unit coordinators (on all shifts, including overnights) to track down paper charts, coordinate tests, call attendings as well as nurses that tell the MDs when everything is back, find missing labs, and give pertinent updates on patient condition. It’s our overall goal on every shift to MOVE PRODUCT, espcecially overnights so we can have wheelchair races and play pranks on each other. The lobby ain’t getting any emptier.

    That’s way more than I wanted to say on this subject.

  37. No it wasn’t a 12 hour shift; it was 9 1/4 hours of a 10 hour shift. It was slow, so I went home early. Scribes make us way more efficient, for one thing.

  38. Jenny D. in Virginia says:

    “Now I can sit down and look at the patient, do my interview, and FOCUS COMPLETELY on the patient while the scribe inputs. I then do all the orders and prescriptions.”

    Article:
    “Hospital Improves ED Discharge Rate by Replacing Doctors with Scribes for EMR “Secretarial Work”

    http://insideemr.com/articles/scribes1-3.html

  39. Jenny D. in Virginia (former scribe) says:

    “We get a much BEEFIER, more complete record than we would otherwise,”

    Article:

    “OCEANSIDE: Hospital uses scribes in the ER”

    http://www.nctimes.com/articles/2008/04/02/news/coastal/oceanside/357c04bda717bf318825741f005c2653.txt