Practice with online tools and resources, evaluating your initial typing speed in words per minute. Improve your body positioning. Do not slump, keep your posture upright. Evaluate your finger positioning. Utilizing the QWERTY keyboard maximally allows faster transcribing. Practice with dictations, listen to something and try typing it out as you. This is an effective method because ultimately you will be typing the physician’s dictation.
In addition to the terminology, it may be helpful to learn Latin roots, thus allowing you to interpret terms that are unfamiliar to you. Not only will learning medical terms allow you to transcribe faster while the physician is speaking to you, but you will be able to get a better understanding of what the patient’s course of treatment will be.
Do not ever hesitate to ask the provider why he placed certain orders on a patient or what the results of the study indicate. Most are happy to help clarify any confusion.
The History of Present Illness is the patient’s explanation of what is going on with him/her, it is crucial that this history is well documented in order for other physicians, billing companies, or authoritative personnel are able to understand the story. Practice writing a History of Present Illness by listening to an online video of a patient presenting to the emergency department explaining their complaints. Ensure you only include information pertinent to the patient’s history. Irrelevant information is not appropriate to be placed into the History of Present Illness. Listen for specific questions the physician may ask patients while they are being evaluated and make sure to include that information in your history. Always ask the physician you are working with if you are unsure of what the patient stated.
Most medical scribes are obliged to sign a document stating that they will keep any information disclosed to them private and secure. There are numerous implications if this is defied by any scribe, which is why it is imperative to emphasize that being a successful scribe implies an understanding that all patient information is exclusive.
This is more of a hands-on approach to allow trainees to get a feel for what exactly the job entails. Mastering how to create notes, modify notes, insert procedures or radiology reports into notes, and input proper diagnosis and disposition information is crucial. Without grasping how to properly use the charting system, you can only be so effective, which is why taking the time to learn and appreciate documenting an interaction will help you in the long run.
Many times, physicians are unable to recall the names of every patient they are evaluating and will refer to them by their patient room numbers. Often times the provider will ask you to meet him/her at a certain room, or patients may even ask you to direct them to their family members. Therefore, becoming acquainted with the site you are working at can go a long way.
Once you are familiar with the physicians you are working with, it will make your profession enjoyable as well. It is all about the first impressions, show the physician you are a respectful, hardworking individual and that will go a long way with them!
This may seem like an obvious task, but when you are trying to formulate a History of Present Illness that is accurate and concise, you may get lost in your work and miss critical details that the patient describes. Some physicians will want you to document any conversations that occur between them and a consulting physician on the phone, which will require your conscious effort to actively listen while this is going on. Practice your ability to listen while writing a History of Present Illness while listening to an online video of a patient explaining to the physician their complaints.
Many physicians will want to have all the charts sent to them before the shift is over, therefore you will need to be on top of the work to make sure they are complete and sent to the provider. Being on time is crucial in this field. It is unacceptable to keep a physician waiting because ultimately you are keeping the patient waiting.
This directly benefits the patient by making sure everything is in place to take care of their needs. Making physicians aware that laboratory or radiology studies have returned also aids the patients and lets the providers know that you are paying close attention to the patient’s care.
Coming into work with a smile on your face and prepared to aid the physician in any way possible is the best mentality! It will go a long way with the physician, you will be showing him/her that you are eager to work hard and soak up all the knowledge you can. Ultimately, doing so will create a stronger relationship with the providers you are working with and the patients being cared for.
