What is a hospital scribe?
A hospital scribe or hospitalist scribe assists medical providers with their documentation. Hospitalists provide general care to hospitalized inpatients from their admission to the hospital until their discharge home. Hospitalists oversee each admitted patient’s healthcare team, which is composed of a different variety of specialists for each patient. Hospitalists must carefully coordinate complex care plans for several patients, so their medical scribes must be skilled at organizing and keeping track of a lot of information.
What is it like to be a hospital scribe?
Hospitalists work together to admit patients to the hospital and manage all of the inpatients. This field differs from other specialties because each patient will have a unique care team depending on what condition they are being treated for. For example, a patient admitted for neurological observation after a stroke will require different providers than a patient admitted for orthopedic surgery to correct a broken hip. So hospital scribes must be well-versed in terminology from an array of medical specialties.
What does a scribe do in a hospital?
A hospital scribe is usually assigned to one medical provider for a workday with each shift ranging from 8-12 hours. Depending on the day and the facility, hospitalists may see between 12 and 30 patients per shift. New patients are assessed first, and then follow-ups are performed. Follow-ups include patients in varying stages of treatment. As the provider visits each of the patients under their care, the hospitalist scribe must be able to quickly update each patient’s chart with little time between patients. Hospitalists provide general care to these patients as they are admitted and during their stay in the hospital.
Most admitted patients were first treated in another department, typically the emergency department, so each patient’s chart will already have a lot of information in it regarding their current visit. For example, a patient that came to the ED for chest pain and is being admitted for cardiac monitoring will already have labs, a chest x-ray, and multiple EKGs already completed. This means that new patients usually take longer to assess and document. The scribe hospital must be able to quickly review all this information entered into the chart by previous providers and relay it to the physician in an effective manner.
What types of conditions do hospital scribes document?
Since patients can be admitted to any department for any condition, hospitalists treat patients with conditions of all systems and therefore hospital scribes should be prepared to document a variety of ailments. Common conditions for which patients are admitted include myocardial infarction, or heart attack, congestive heart failure, stroke, pneumonia, and conditions that require surgical intervention. Common conditions among pediatric inpatients include pneumonia, influenza, infections, and complications of chronic conditions such as asthma or diabetes.
Most hospital patients will have already been stabilized before admission and will be treated by appropriate specialty providers after admission, so hospitalists provide general care to ensure that proper treatment is provided and that patients are comfortable. For example, if a patient who is admitted to the hospital for pneumonia does not already have a respiratory therapist on their care team, the hospitalist will assign an RT to the patient. If the patient is found to require antibiotics upon admission, the hospitalist will also prescribe the appropriate medication.
How to become a hospitalist scribe?
Most hospital scribes are first trained in another specialty, such as internal medicine scribing. This gives scribes a good base of knowledge in general medicine and terminology, which is an important skill to have for a hospital scribe job. Hospital scribes tend to have a lot of autonomy compared to scribes of other specialties because most of the documentation requires adding updates to patient charts based on notes from other providers, labs, and imaging results. Having a strong background in other scribe specialties shows that you will be able to handle documenting these updates with minimal dictation.
There are multiple routes you could take to become a medical scribe. The most common is to apply for a position with a large scribe training company. These companies hire, train, and employ scribes all across the country including states like California, Texas, Florida, Illinois and New York. You could also take a scribe training course that is affiliated with a college or university, some of which provide certification and offer paid positions upon graduation. There are also online scribe certification courses that you can complete on your time, which are excellent for aspiring scribes with unpredictable schedules. Certification as a medical scribe boosts your resume when applying for scribe positions, as it shows dedication and adds to your credibility as a potential scribe.
How can hospitalists benefit from employing medical scribes?
The burden of documentation affects all medical specialties, and hospital medicine is no exception. With so many patients with vastly different treatment plans, it can be difficult to coordinate care teams while keeping track of all the documentation required for each patient. Documentation can also take away from valuable face-to-face interaction with patients and cause unnecessary delays in accessing patient information.
Many hospitalists report that documentation takes a backseat to their other, more pressing responsibilities. This can result in unfinished charts building up over time, which forces providers to stay late past the end of their shift, complete charts at home, or try to catch up on charting during future shifts. All of these options lead to errors in charting, increased workload, and physician burnout.
How do Hospital scribes Help Doctors with Charting?
Clinical scribes can access patient charts as they are entered into the system, review the history, and efficiently relay pertinent information. Scribes also document each encounter in real-time, leaving the provider free to spend more time with their patients. Scribes can also increase provider efficiency by communicating relevant information during the encounter, so the provider can continue providing care without interruption. Having a scribe to document in real-time allows providers to see more patients per shift, spend more time with each patient, complete charts on time, and finish shifts on time.
Studies have also shown that using hospital scribes to assist with clinical documentation can decrease patient wait times which increases patient satisfaction. The benefits of scribes for both patients and providers leads to an overall improved healthcare experience for everyone involved and minimizes the risk of physician burnout.