A Day in The Life of a Medical Scribe

Hey guys! Below I will be sharing what my daily routine was as an Emergency Department Medical Scribe. 

Depending on the shift I would go in at either 9-6pm, 2-11pm or 6-3am (I usually worked the 9-6 or the 2-11 shifts). I had the pleasure of working with Physicians, PAs and NPs. I would get to work about 10-15 minutes early so that I could get set up and have time to get my breakfast together before my shift started. (Sometimes that was a stretch the way Nashville traffic was set up lol). We used laptops to chart, so I would open the charting system and a word document so that I could write my HPI (History Presenting Illness) before putting it into the system. In order to help me out, I would type something along the lines as: “The patient is a year-old male who presents to the emergency department for evaluation of. . .” This would help me write my HPI’s quicker once I started seeing patients with my providers. When my provider signed up for patients we would head to their rooms to see what was going on. Sometimes I was able to finish the HPI in the room and if the visits were more complicated I would most likely finish it back at our desk. The HPI is basically a more detailed story of the chief complaint. I would write down what the patient said including symptoms, etc.
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 For example, if a person came in with abdominal pain; I would say something along the lines as The patient is a year-old male who presents to the emergency department for evaluation of abdominal pain (or I could be specific depending on where the pain is and say left upper quadrant abdominal pain) that began 12 hours ago. The patient reports vomiting, a fever and denies a headache or any rashes. The patient states that he ate a shrimp pasta dish at a new restaurant last night. There are no other signs, symptoms or complaints other than noted.
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After completing the HPI I would go ahead and complete the ROS (Review of Systems) and the Physical Exam. Some providers gave the physical exams in the room and others would wait until we got back to our desk to give it (this part really helps with your medical terminology; rhinorrhea? Why can’t I just say a runny nose lol) I would complete this process for each patient that my provider picked up. Another task we were responsible for was asking the patients their social history which could very awkward at times. Tayler: Do you smoke, drink or do any drugs?  The patients usually responded quickly, paused or looked at me like “why are you asking me that!” I would say it’s something we are required to ask every patient so that we can put it in your chart.  As a scribe in our ED, we would also pull lab results, X-rays, CT’s, etc. for the providers. We were also responsible for putting the results into the system until our system updated and we no longer had to input them (easy for us 😊)

I worked in a rural area and was blessed to be able to see a variety of cases in the ED. The providers, nurses, techs, etc. that I had the pleasure of working alongside were amazing! The providers knew that a lot of the scribes were getting ready to apply to school and they were very helpful. They would take time out to teach me things that were very informative. If they were doing procedures, they would allow me to come and watch which was pretty cool! I was able to see the daily routines of everyone in the ED. One of the most important things I learned while working as a scribe in the ED was that we are a team! Everyone is needed whether you are the provider, nurse, tech, scribe, registration, housekeeping or security. We all work together to serve the patient; no one can do it alone.   

Here's some jazzy and funny pics of my work fam bam! God blessed me which such a great family while scribing!