Behind the Curtain: A Day in the Life of an ED Scribe

By Franklin Pachay, Jr.

“Clinical Information Manager,” or simply “CIM,” is my reply when a new face in the emergency department (ED) asks what I do. The reaction that follows is probably best described as awkward confusion. I make sure to follow through by explaining that I’m a medical scribe and outline a few things that I do: I help create the physician note; I get the radiology results into the charts; I follow up with labs; I increase clinician productivity. The person who is asking usually exclaims, “Oh! You type the charts!” I smile, nod and leave it at that. The reality is, there is much more to it than just “typing charts.”

My background aligns with most other medical scribes. I studied science as an undergrad and have always been fascinated by medicine. Many of my fellow scribes got into the job as a way to work side-by-side with doctors and midlevel providers (PAs and NPs) with the goal of obtaining experience before their move up to the next rung of the professional ladder. The exposure to what medicine “is really like” becomes invaluable. It’s definitely not Grey’s Anatomy, House or whatever your favorite medical TV show may be.

Generally, there are three ways to work as an ED scribe:

• Time permitting, you can follow the physician into the room and take notes during the physician-patient encounter. Patients’ medical histories can be very complex. They can easily start talking about one thing and hop into a seemingly unrelated complaint. You have to talk over the case with the physician to make sure you’re both on the same page – especially to assemble the bits and pieces to complete a history of present illness. You’re then able to see how physical exams are done. With time, you’ll witness the proper way to do abdominal exams, neurological exams, chest and respiratory exams, full trauma exams, etc. It’s a great way to learn.
• The second way is to take dictations from the provider several patients at a time. This is probably the most efficient way when there are a lot of patients and you’re working with multiple providers. For example, I work with two attending physicians and a midlevel provider in the ED. The work builds up quickly and it tests your organizational and listening skills and ability to work under pressure.
• The third way is a mix of the previous methods. I’ll take dictations and work on the notes, but make myself available to see the more complicated or time-consuming cases with the provider. For example, trauma alert activations and cardiac arrest are cases where an immense amount of information is flowing and you have to record all of the findings, medications and history to produce a chart that accurately documents what happened during the patient’s ED visit.

I start my shift by peeking into the waiting room during my walk into the ED. Usually there are a handful of people in the waiting room at 7 a.m. Other times, I’ll only hear the morning news blaring from the waiting room TV, with not a soul in sight. The emergency department can be eerily quiet as you walk in. You’ll see the clean, ready stretchers lined up in the rooms. The tired, battle-worn overnight staff is giving turnover reports to the morning staff while adding in water cooler small talk: the weather, gossip, new toys at home, the kids, the spouse, recent vacations, etc.

I get to my location, seated next to the ED physicians and midlevels, and greet them. My next step is to look at the patient tracking board. Two patients are waiting for CT studies, one pending an ICU consult, two are waiting for surgical consults, another pending sobriety prior to discharge, six admissions are waiting for inpatient beds, and the waiting room has about four cases of varying acuity. Not a terrible way to start the day.

Not long after the beginning of my shift, one of the doctors will dictate a few notes. With paper and pen at the ready, I get set.

“John Doe in room 8 is a 47-year-old male complaining of non-radiating epigastric pain and nausea since 3 a.m. He does have a history of gastritis and reports having consumed spicy foods and beer last night. He took Maalox with no significant improvement. Otherwise, no chest pain, vomiting, diarrhea, fever, dyspnea, GI bleeding, urinary complaints. His review of systems is unremarkable except for recent exacerbation of his chronic lower back pain, which is not bothering him now. Patient has history of hypertension and had a cholecystectomy 5 years ago. He smokes 1 pack per day and is a social drinker; no drugs. His father died of an MI at age 74. Medications: Maalox and Metoprolol. No allergies. Patient is awake, alert, and in mild distress. Vitals are in the nursing note and are normal. Exam is normal except for mild epigastric tenderness without guarding or rebound, and bowel sounds are present. Normal heart sounds, clear lungs, good distal pulses. His EKG is sinus rhythm at 78 beats per minute with no acute changes. I can’t find an old EKG to compare. We’re going to give him some GI medications, observe him in ED, and do some blood work including cardiac labs. I’m not sure if we’re keeping this guy yet; I’ll re-evaluate him after his meds and we see his labs.”

That sounds fair enough, right? Have someone read that out loud to you while you scribble the notes in less than 30 seconds or so. Not impossible, but you have know the language and pay attention to the details.

“Jane Doe is an 8-year-old girl whose mother states that she twisted her left ankle while running around with friends yesterday afternoon. Patient has been able to walk, but with pain. Mom gave her Motrin with temporary relief. She does have a history of prior left ankle sprain two years ago. No other injury. No other medical history, medications, or allergies. Exam showed a smiling little girl who’s interactive with mother and me. She does have some mild anterior lateral left ankle tenderness with no deformity or swelling. She has full range of motion of ankle and foot but with pain. Good DP and PT pulses. She is able to move all toes. Her X-ray was already done, showing no fracture or dislocation. I’m going to place an Ace wrap, and the nurse will instruct patient in crutch walking. Mom instructed to continue giving Motrin for pain as needed. They will follow up with their pediatrician in 2 to 3 days.”

I love these! They are to the point and not overly complicated.

Sometimes I get dictations with three or four unrelated complaints with various time frames and complicated outpatient workups. The exams are very detailed and I have to follow up on labs, X-rays, CT scans, EKGs and urine analyses, and document re-evaluations of the patient. Then I have to document the consults and conversations with the patient’s primary doctor and cardiologist. The patient “cannot afford his medications,” so social services get involved, adding to the documentation. Then, the patient’s condition worsens to critical.

Something happens, such as the patient developing very low or high blood pressure, a fast or slow heart rate, a change in mental status, a seizure, or difficulty breathing. The doctor re-evaluates the patient, orders more medications with IV drips; more labs are drawn, and the consults are contacted again. The primary physician is contacted again and agrees with ICU admission. I keep track of all of this information in an organized matter. It can take a long time to document all of the changes, discussions, results and dispositions. Sometimes I wish I had more ankle sprains to write about, but what is the fun of that?

I repeat this process multiple times during the shift between the providers I’m working with. I write about abdominal pain, chest pain, shortness of breath, lacerations, head injuries, psychiatric emergencies, pregnant patients who are bleeding, leg pain, strokes, and I can always count on someone coming in with a cold to request a note for work. Some days it seems like there must be complimentary shuttle buses to the ED as patients come in droves!

Focus is an important aspect of the job. I’m trying to get EKGs and radiology reports, and make sure I’ve written all the notes being dictated. I work through background noise as I try to pay attention to dictations when there are four other conversations within a 10-foot radius. Then the nurse asks me to give the doctor a message. My hearing, sight and even smell are all activated in this sort of total information absorption. I’m managing clinical information in a high-paced environment to compose a detailed, accurate, medical record that will reflect the whole visit for others who care for the patient as well as his insurance company and—sometimes it comes to this—his lawyer. No mistake is too small to be important.

The job certainly has its rewards. I’m exposed to so much knowledge, and everyone wants to teach if asked appropriately. The providers explain what to look for in chest X-rays and EKGs. It gets to the point where you almost know exactly what they are going to order for specific complaints. And you learn to respect the confidentiality and privacy of every patient. You never look at charts that aren’t yours, discuss patients except with their doctors, or put any information on your Facebook page.

I’ve been able to watch our providers perform a variety of procedures, such as endotracheal intubations, spinal punctures, laceration repairs, incision and drainages, dislocation reductions, chest tubes, transcutaneous pacing and central lines. I’ve seen nurses start IV lines in mere seconds and have wondered if they can do it with their eyes closed! I’ve seen teamwork and organized chaos as someone is rolled into the ED by EMS after cardiac arrest. I’ve seen lives being saved.

No, it’s not TV. It’s better.

Franklin Pachay Jr. earned a bachelor’s degree in biology from Ramapo College of New Jersey. He has worked as a medical scribe for Emergency Medical Associates since 2008. He is based primarily out of Jersey City Medical Center, however, he also has worked at Christ Hospital, Clara Maass Medical Center, Meadowlands Hospital and Medical Center, Benedictine Hospital and Roger Williams Medical Center. When he is not in the emergency department, he also works as an EMT and EMS supervisor for the Borough of Paramus, N.J.

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