Scribing: ER vs Outpatient

Phew. It’s been a hot minute since I posted about scribing. I scribed for a total of 6 years, both in the ER (for 4 years) and outpatient (for about 3-4 years). There was a year or two where I did both (I know, I’m crazy).

From my previous posts, you should have an idea of what a medical scribe is and what the training is like for you as a new scribble. If not, head on over to the side bar and check those out. But believe it or not, scribing in different types of medicine is not necessarily the same. The overall general core of scribing is similar, but how they function is very different.

So, let’s dive in!

A Day as an ER Scribe:

In an ER, there are no set or scheduled patient visits. This means that each day is different. You could walk in to a rack with 7 patients to see or you could walk in with nothing. It all depends on how crazy the day went or is about to go.  But before you can start scribing, you have to know what shift you are on! There were several shifts that I could have been scheduled for as an ER scribe at the hospital I worked at as seen below:

There was one peds only team and 3 adult teams. The hospital was set up in corners, such as a square. Blue team (which was right by the resuscitation bay), brown team (also close to the resuscitation bay), green team (in the back corner, held most of the psych rooms) and red team (the other far end corner, the pediatric unit). Near the resuscitation bay but off to the side was minor care (meaning small things that could be easily taken care of) and an overflow/triage bay as well. Splitting the two sides (between resuscitation bay and minor care) was the hallway where EMS would come in/check in a patient. Towards the back was actually the entrance to the observation unit (24 hour hold unit). Near the red team was the door for the the helicopter (which yes, was called!).

The midday shift (2pm-12am) was by far the busiest. The morning and evening shift would have periods that would lag a bit more and then get intense. So in the morning shift, it was usually pretty quiet until 10 or 11 am on most days, (meaning like only a handful of patients showed if at all) before picking up, and then at night the busiest part would be when you first arrived and would trail off as the wee hours of the morning hit.

A typical day for me was anywhere between 15 and 25 patients in an adult shift. If we were working a peds shift, there was usually a pediatric NP (or nurse practitioner) there who saw most of the patients, and I would just write a “yea I saw the patient as the physician and agree with the NP” type note if I ended up seeing a lot of patients with the physician as well. If not, I would scribe with the NP’s so they had less notes to do. So I would typically see upwards of 30+ patients due to this.

When I would show up is when the other doctor/scribe team would stop seeing new patients, but would finish up their current patients. Then as the new team starting, we we would just jump into seeing patients. As I didn’t know who would be showing up to the ER that day, it was pretty hard to prep.

Once a chart was placed in the rack, I would open it up on my online EMR (or electronic medical recording) system and look to see what notes the nurses took and to see why the patient was there that day. Very similar information was on the paper version of the chart sitting in the rack. If I had enough time, I would look to see if they had been in the ER before (or at least very recently), if they were part of the overall hospital system we worked at to see if there were any recent family or specialty notes that were available/of use to today’s visit, and their medications list. All of these things would not only help supplement my note, but if there was something important that the physician needed to know before we went in or after coming out to see the patient, I could inform them of this information. (Such as if they were on a blood thinner which is always important to note-no exceptions!). 

Once the physician was ready we would go in and see the patient. The provider would obtain the history and physical exam, and generally explain a few things that they would be planning on testing the patient and go from there. We would exit the room, and if I was working with a provider who would dictate the entire physical exam to me, they would do it once back in the workstation. If not, then I would ask for clarification and do it myself.

Either the provider would then tell me what they were ordering or I would look in the chart to see what orders were placed. I could then add this as a timestamp so we could monitor when anything critical came in.

Then we were on to the next patient!

Typically a patient could be there anywhere from 4-8 hours in the ER. Sometimes it would be something ridiculous like 15+ hours if they couldn’t get a bed and the hospital was backed up. Patients are either admitted, placed in observation (a 24 hour hold unit, used to follow up something small or quickly see a specialist), or get discharged home.

If all labs/imaging were back and the provider had a diagnosis, we would go back in and let the patient know. If there was anything urgent or that we needed to update the patient on, or say they had a change in symptoms after medication was given, we would stop in and see them before giving them the final discharge or admitted discussion. Otherwise, we would go in after everything was done, give the results and the diagnosis, and explain the plan.

The whole time (even when we weren’t directly seeing the patient) I would be updating the note and time-stamping appropriately. This would include when labs came back and what they showed, if any other physicians were called and the case was discussed, if the patient was in pain and needed more medication or if the medication worked wonders, any new ailments/complaints, you name it. Once the plan was given to the patient, we would come back to the team room and I would be dictated the medical decision making (the thought process of why things were done the way they were and the plan). For some providers they dictated the whole thing to me, others only parts of it, and others had me do it entirely by myself. The provider would then prep the patient for discharge and the nurses would ultimately discharge the patient, give them their discharge paperwork (or home notes, what to do, explanation of what they had), and they would give any prescriptions or specific follow up notes.

At any time, we could be called to a resuscitation. The teams rotated between who would get called in to take the call. Some days there weren’t that many, some days there could be 4+ resuscitation’s going at the same time. If we weren’t busy and it wasn’t our team called, the docs would show up to assist if needed. Otherwise, we would go back to taking care of our team. You still get patients arriving at your team to see even if you are in resuscitation. So if its a super busy night or you are in a long, stressful resuscitation, you will still get patients to see once coming out.

The nice thing though, was if you were in a long resuscitation and you kept getting pummeled with more patients, usually another physician who wasn’t in resuscitation would come over and see a couple of your patients so you wouldn’t be as far behind. Usually, but not always. There were always a handful of asshole physicians I worked with who refused to be nice.

At the end of your shift, there would be a new team coming on. We would stop seeing new patients and try to wrap up any patients that we could (i.e. admit, discharge, etc) so the other physician didn’t have to. If something was going to take a very long time, we would sign it out to the next team. I would stay anywhere between the 1-2 hours allotted for me to after the next team arrived to up to 4+ hours after if we had a lot of patients to finalize or had a very sick patient.

There were days where it was really hectic, but honestly, there was a lot of downtime. Especially at like 3AM.

A day as an Outpatient Scribe:

Okay, outpatient scribing schedule is much much different. First of all, time-stamping events is not necessary in outpatient events as there is usually nothing critical. If it is critical, we call an ambulance or tell the patient to get to the ER immediately. That’s it, no admission, no lifesaving-hours long resuscitation bay sessions. They either get discharged home (like normal) or we send them to the ER if we are concerned.

Side note: what is considered an emergent situation by a family medicine or internal medicine physician IS NOT the same as an emergent situation to an ER physician. From working in both, I could tell you that probably 50% of the things an outpatient physician sent their patient to the ER for would likely have been a WTF by the ER physician. However, it is always important to air on the side of caution. So even though it likely wasn’t needed, it was still safer to have sent the patient and discharge them home for nothing than for it to be an actual big deal.

Just thought you all should be aware of that fact. Because I’m writing this and that’s why. So there.

Okay, so scheduling. This is like your typical outpatient schedule that most of you are aware of since you call and make your appointment and then show up. Depending on the specialty will depend on how long the appointment times are. They can also be further broken up into RV’s (return visits) or NP’s (new patients). NP appointments are always much longer than RV’s. I’m just going to show a typical internal medicine morning shift, but slots can vary from 15 minutes to 1.5 hours (again, depends on the specialty and the type of visit).

RV’s here could be for a direct follow up for something (commonly hypertension or diabetes), or say wound check, or it could be for any patient coming in for a complaint but has been seen in the clinic before. So this would be when you go see your physician when you have a cold, or you have elbow pain, or whatever it is you are seeing them for.

NP’s and HME’s (health maintenance exams or yearly physicals) are always given an hour (or the longer appointment slot depending on the clinic/speciality). Usually if NP’s have a lot of complaints, they have to return for an RV to check up on things recommended from their NP visit, and it allows the physician to give more time to check up on the lesser concerns of the patient. Note: lesser concern does not mean that the patient is not concerned about it. It usually means it is not high priority in the physician’s mind. So for example, if someone comes in complaining of knee pain and chest pain, the physician will always evaluate the chest pain first (concern for cardiac–> can kill) and then evaluate the knee pain later. 

HME’s are established patients who need the whole allotted time as they usually have several complaints to get checked up on, need a full head to toe exam (not just a basic exam or problem focused exam), and usually need several blood work orders and/or other studies. There are times where people coming in for HME’s take the full time, and other times they tend to be generally healthy and don’t require the full amount. Either way, they get scheduled for the full time. (It just may mean that if we finish early I have time to finish other notes!).

The afternoon would look pretty similar and would end anywhere between 4:30PM and 6:30PM. If things were really bad maybe 7PM. Working in this way tended to be more exhausting only because you never really had a true scheduled break. Most of the time you would run over and most patients showed. You can still usually see upwards of 20-25+ patients in outpatient (more specifically specialty than internal medicine), and without the benefit of knowing you’ll have downtime.

But the hours are more normal business hours and less suckage then having to work in the middle of the night in the ER.

Charting Differences:

So now you’ve seen the schedule differences. Charting there are differences as well. I’m not going to completely go into a breakdown, but I will explain a few key differences.

• HPI. HPI, or History of Present Illness is the story you gather from the patient about what their concerns are, what associated symptoms they have, what they did to help it or what made it worse, the inciting incident, all of that jazz. In the ER, you are only concerned about the main complaint. Sure, you can add the laundry list of complaints that the patient is having, but you only really focus on the main 1-2 complaints that they came in for. Was it chest pain? Was it abdominal pain? Where they having a miscarriage? Did they come in after a stroke? Usually your HPI’s were only 1 paragraph (which could be a few sentences to a very long paragraph), maybe 2 paragraphs at most. But that is it. In outpatient, you literally have a paragraph for every problem. And since in outpatient you need to evaluate every concern (again, you send the critical patients/concerns to the ER) and you keep a running tab of how things are playing out over time, you have a plethora of paragraphs. Sometimes it is just 1-2 paragraphs, but usually its like 5-10 paragraphs depending on the patient. So much more overall detail is captured in outpatient.
• Following up on labs/imaging. In the ER, you follow it while they are still present in the ER. If anything critical comes back, you need to act on it. If everything comes back okay, you let them go home. The difference is, you don’t discharge your patient home without everything being back. If it’s taking awhile, you admit them or place them in observation until the testing results return. In outpatient, you never usually wait for results. Unless it is a fast and easy in-house test, such as blood sugar, strep swab, or pregnancy test, you send the patient out the door and call them in a week when everything returns.
• MDM vs diagnosis & plan. In emergency medicine, you have what is called medical decision making or an MDM. This basically is a summary of why the patient presented and with what symptoms, what we did to treat it, any highlights of what happened during there stay, why we ordered what we ordered, any differential diagnoses considered, and the plan. Then in all of the charts at the hospital I worked at, there was a separate line for discharge status (admitted, obstruction, discharge, deceased, etc) and then a line for the final diagnosis (or diagnoses). In outpatient, there are so. many. ways to do this but the most common form I wrote in was one separate line/paragraph for each diagnosis or related diagnoses and the plan for that issue/diagnosis. There were usually many in outpatient, and usually had a lot of information the physician discussed with patient so this was a much bigger chunk of the chart.

 

And there you go! Let me know what you liked, what you want to hear more about, or any other topics you are interested that I may be able to assist with down in the comments below.