By Catherine Palmigiano, Scribe
Have you ever considered becoming a scribe? Let me tell you how I entered this fascinating area of vision health care. I was hired at my current practice as an ophthalmic technician. The practice took notice of my attention to detail, time management skills, and general interest in the field, and offered me the opportunity “upgrade” and train as a scribe.
The first step in training was to discuss with the doctors the multitude of areas and standards related to proper coding for eye exams and medical testing. A scribe’s duties require coding input for existing and new patient eye exams with stringent accuracy. We must make sure details are correct and coding entry provides the necessary level of detail required by medical testing performed at optometry and ophthalmology offices. Initial training and orientation required lots of memorization and repetition. The training process takes several weeks to acclimate a new scribe to the many patient scenarios that come up. When that training was complete, I was tasked with coding all the patients for a particular day, and the doctors noted and corrected any errors.
For the second training session, I was in the exam room with the doctor and patient. I had a laptop to compile all information the doctor acquired during the exam, such as intraocular pressures, visual acuities and cup sizes of optic nerve heads. This information must be entered accurately in the proper chart area as well as large and small single medical impressions . The training isn't difficult, but is repetitive. The secret to repetitive data entry was to develop a method to use every time. It’s actually quite simple - copy all the information the doctor says aloud during the exam and input that information into the chart during the refraction process.
The third training session involved discussing best practices when determining which medical impressions to input into patient charts. We found a simple way. The doctor verbally stated the particular ICD code for that medical diagnosis and I entered it into the chart and added all the testing required for that particular code set. Another method was to enter the diagnosis when the doctor educated the patient on what was found in the screening test. This approach is a bit subjective because it depends on how well the doctor can relate to the patient and how well the scribe and doctor work together. Sometimes the outcome is maximized with patient interaction, but sometimes it requires a more intuitive method.
Keep It Simple
The fourth training session I found to be the most difficult. To effectively condense the large amount of information I collected, I had to develop a different way of thinking; one that I had not been accustomed to. Because of the technical nature of the data, it can come across as very abstract, and I had to develop a way to condense the information and keep its relevance to the exam, the doctor’s speaking, and my own notes. The method is straight forward - keep it simple, condensed, and to the point.
Scribing is an ever evolving job and nothing in the medical field ever seems to stay the same for long. With new technology and insurance rules, scribing is a great field for someone who likes change, challenges and always having something new to learn.