Comments on: Scribes in the ED http://gruntdoc.com/2007/06/scribes-in-the-ed.html Ramblings of an Emergency Physician in Texas Wed, 23 May 2012 13:20:52 +0000 hourly 1 http://wordpress.org/?v=3.3.2 By: Jenny D. in Virginia (former scribe) http://gruntdoc.com/2007/06/scribes-in-the-ed.html/comment-page-1#comment-16193 Jenny D. in Virginia (former scribe) Sun, 25 Jan 2009 16:04:49 +0000 http://gruntdoc.com/2007/06/scribes-in-the-ed.html#comment-16193 "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 “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

]]> By: Jenny D. in Virginia http://gruntdoc.com/2007/06/scribes-in-the-ed.html/comment-page-1#comment-16192 Jenny D. in Virginia Sun, 25 Jan 2009 16:00:23 +0000 http://gruntdoc.com/2007/06/scribes-in-the-ed.html#comment-16192 "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 “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

]]> By: GruntDoc http://gruntdoc.com/2007/06/scribes-in-the-ed.html/comment-page-1#comment-6150 GruntDoc Mon, 11 Jun 2007 18:02:47 +0000 http://gruntdoc.com/2007/06/scribes-in-the-ed.html#comment-6150 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. 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.

]]> By: Kelly http://gruntdoc.com/2007/06/scribes-in-the-ed.html/comment-page-1#comment-6149 Kelly Mon, 11 Jun 2007 15:59:31 +0000 http://gruntdoc.com/2007/06/scribes-in-the-ed.html#comment-6149 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. 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.

]]> By: GruntDoc http://gruntdoc.com/2007/06/scribes-in-the-ed.html/comment-page-1#comment-6148 GruntDoc Mon, 11 Jun 2007 09:15:17 +0000 http://gruntdoc.com/2007/06/scribes-in-the-ed.html#comment-6148 <p>Nurse Kelly,<br /> 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.</p> <p>Again, thanks for pointing out the barriers thrown up to scribe implementation. <i>Nearly always by nurses</i> 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' <i>three hours</i>. <b>Three hours</b> 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?</p> 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?

]]> By: Kelly http://gruntdoc.com/2007/06/scribes-in-the-ed.html/comment-page-1#comment-6147 Kelly Mon, 11 Jun 2007 08:57:11 +0000 http://gruntdoc.com/2007/06/scribes-in-the-ed.html#comment-6147 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. 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.

]]> By: GruntDoc http://gruntdoc.com/2007/06/scribes-in-the-ed.html/comment-page-1#comment-6146 GruntDoc Mon, 11 Jun 2007 07:24:41 +0000 http://gruntdoc.com/2007/06/scribes-in-the-ed.html#comment-6146 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. 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.

]]> By: shadowfax http://gruntdoc.com/2007/06/scribes-in-the-ed.html/comment-page-1#comment-6145 shadowfax Mon, 11 Jun 2007 05:42:47 +0000 http://gruntdoc.com/2007/06/scribes-in-the-ed.html#comment-6145 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 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

]]> By: jerry http://gruntdoc.com/2007/06/scribes-in-the-ed.html/comment-page-1#comment-6144 jerry Mon, 11 Jun 2007 01:10:46 +0000 http://gruntdoc.com/2007/06/scribes-in-the-ed.html#comment-6144 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? 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?

]]> By: ERMurse http://gruntdoc.com/2007/06/scribes-in-the-ed.html/comment-page-1#comment-6142 ERMurse Sun, 10 Jun 2007 16:53:52 +0000 http://gruntdoc.com/2007/06/scribes-in-the-ed.html#comment-6142 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. 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.

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