Make sure the use of scribes doesn't lead to medical or charting errors.
One concern you may have when including a non-clinician in your exam routine is the possibility of creating problems in your charting and patient care. Here are some preventive measures that have proven helpful to practitioners.
ALWAYS ON GUARD
“Errors can occur, even if you're doing everything yourself,” points out Dr. Antoszyk of Charlotte. “The more patients you see, the more risk there is of incorrect data going into the EMR. We have multiple levels of review, and communication among all staff members is emphasized, with the goal of maximizing accurate charting and minimizing the potential for clinical errors.”
Dr. Antoszyk says his scribes record data and critically review charts. If they see discrepancies, they ask him for clarification. He reviews charts after completing his exams and then signs off on them if the information is complete.
“If, however, we're busy or I have a new assistant, I defer signing off on the chart until I've had time to review it more thoroughly,” he states. “I typically do this at night or on weekends.”
In addition, Dr. Antoszyk says scribes and technicians minimize risk by marking the operative eye after confirming through the patient that it is the correct eye. “This is reconfirmed when I enter the room,” he adds.
Dr. Antoszyk notes that his practice is very interested in quality improvement. An active compliance committee—comprised of physicians, a compliance officer, business office staff and administrative staff—checks random charts for each physician. “Feedback is provided to physicians and staff,” he says.
CHECKING THE DATA
Starlyn Miller, who scribes at Charlotte Eye Ear Nose and Throat Associates, says she works to reduce risk by checking exam data while the physician examines the periphery of the retina. She ensures blood sugar levels are within normal range, checks visual acuities against previous exam findings and looks for high pressures.
“I will tell the physician if anything raises a flag,” she says. “I also make sure I don't write anything down unless I'm certain of what he has said. You have to be willing to say, ‘I didn't hear that' or ‘Can you repeat that?'”
“One slip of the finger can turn an OS into an OD in the EMR, resulting in an injection in the wrong eye,” points out Angel Williams, another scribe who works with Dr. Antoszyk and Ms. Miller. “We've instituted a triple check on every patient. The work-up tech starts the process by entering all of the data, including history and reason for the visit. I double check everything, and the physician triple checks the data, so we're certain of what we're doing before the doctor signs the record.”
LISTENING TO THE PATIENT
Dr. Benz says he relies on the information that the patient gives him as much as the data his scribe records. “Knowing your patients and when to follow up and ask questions yourself is critical,” he says.
“Administrative technicians need a lot of supervision,” says Dr. Brown. “They're likely to be more compulsive about details that you may not want to include, for example. You have to captain the ship.”
Dr. Brucker says he waits to read over scribes' notes at the end of each day. “Anything that needs to be done can be completed at that time,” he adds. “We can close out 40 to 45 visits in no time.”
“Be sure the exam is properly documented,” says Dr. Harris. “You should also watch for costly documentation errors. If you can't collect for an injection, you will need to administer 16 injections before you can offset the tremendous financial loss associated with such a costly oversight.” RP
Retinal Physician, Issue: March 2011