Scribing: Tips for Improvement

So you’ve finally made it past the interview, past the typing test, and all of the hurtles of classroom training as a new scribe. Congrats! You earned it! But you aren’t quite done yet.

As I talked about in a previous post, once you pass all of those hurtles you still have to pass floor training. This time, you are actually seeing patients in real time, documenting the encounter as it happens, and thankfully since you have no idea what you are doing as a new scribe, you have a trainer there to watch your every move (and probably for the first 1-2 shifts redo almost everything you do).

So how do I improve my skills?

The #1 thing that is likely slowing you down and making it difficult for you to have a great chart or a complete chart is not having a good short hand. There is no way you are going to get every single word correct when being dictated to. I’ll let you in on a secret: most scribes add or change words after being dictated too. But you cannot do this until you understand how medical dictation works and you’ve seen or written enough of it. So until you can comfortably do that and make it sound great, you’ll have to type down every word your provider tells you.

1. Figure out your short hand. This can be typing down majority of the word and moving on, (i.e. cards for cardiac/cardiology, etiol for etiology, etc). Another is to just have your own system of words/acronyms you use. Utilize the abbreviations that you are taught in classroom training; it’ll make your life so much easier!
2. Practice your listening and typing skills. This will get you just as far as the above and greatly improve what you capture correctly. To do this, sit in front of a television, or pop in your favorite podcast and start typing what you hear. Something that you haven’t heard before but can type down a conversation. Start slow, such as a kid’s show, then build up to say a sit-com or a normal conversational pace, and then if you are feeling daring try for a commercial. You can even start typing down conversations of people you live with! I’ve had many scribes in training listen and type to their parent’s conversations or roommates talking. Don’t worry about spelling or grammar. Just type and improve the function between what you are hearing and your fingers typing.
3. Get familiar with your chart/EMR. Know how to access previous notes/charts, how to filter so you only see certain specialties if you need it, where to find previous labs/imaging, etc. That way, if you need to add additional information or verify something, you can easily find it and augment your chart or help your provider.
4. Practice writing your charts! There are many resources online to help you do this. I received a manual when I worked at ScribeAmerica, so there were practice scenarios already in that manual. All I had to do was either try to write my HPI or physical exam from the prompt given. OR, you can ask your friends and family to poorly act it out for you! Your scribe company may also have practice videos online as well that you can access. As a trainer, I had a plethora of practice scenarios that I would have available for my scribes to use if they needed additional practice.
5. Don’t be afraid to ask. Your provider may be ticked that you asked them to repeat something, but at the end of the day they would rather it be correct than wrong. If you aren’t quite comfortable asking your provider for clarification the first couple of shifts, that is what your trainer is for. Your provider and trainer should know that as a newbie, you will need time to get it right. The assumption is with time, you will be able to capture more correctly and ask less for constant repeating information.

The more exposure you have, the better you will become. Don’t be down on yourself if you cannot get the hang of it the first shift! You will get there. If you aren’t making enough progress your trainer should be honest with you every step of the way. As long as you are improving throughout your floor training, then you should be able to eventually progress to being on your own.