Scribe Notes

Dr. Mahmood Vahediam, MD, MS, FACEP

Scribe Program Director

Scribe Duties

• Document ED provider/patient visit

• Goal: provider should just be responsible for reviewing and signing documents

• Import all the external information to the patient medical chart (labs, imaging, medications, calls/consults, etc.)
• Facilitate the providers time management aka BABYSITTING

• Remember to redirect provider as often as needed

• Relieve the provider from time consuming tasks

Understanding Billing By Chart Levels

Difference between a level 3 and a level 4 chart is $53.38. Difference between a level 4 and a level 5 chart is $53.99.  **Take home message: time is money and we can’t afford to mess up the level of these charts with careless mistakes (messing up by 1 click)!**

Understanding Billing By Chart Levels Continued

Purpose of the Medical Record

• Permanent document of patient care
• Communication between various providers
• Legal document of care

Purpose of the Scribe Sheet aka BFF

• Help the scribe to organize the interaction between the provider and patient.
• Important tips to remember:

• Always record the room number on the scribe sheet (room number will be used more often to identify a patient then their name)
• Make the right side of the scribe sheet your BFFL

9 Key Components of the POWERNOTE

1. Basic information
2. History of Present Illnesses (HPI)
3. Review of Systems (ROS)
4. Health Status (allergies, medication history, etc.)
5. Past medical/surgical hx, family hx and social hx

**REMEMBER medical/surgical hx count as 1 for billing purposes**

1. Physical Examination (PE)
2. Medical Decision Making
3. Procedures
4. Disposition

**REMEMBER for any of the key components of the POWERNOTE, if you don’t know, leave it blank. DO NOT use inaccurate information.**

[Basic Information]

• Time/date seen (timestamp powernote every time you re-enter it)
• History source

• Patient (unless unresponsive, altered, child, etc.)
• Family
• EMS (if transported by ambulance)
• Interpreter (must ass Ciracom ID/video/name of interpreter) **REMEMBER to ask for interpreter name or card if not provided for you**

• Remember to use scribe macro, followed by first initial/last name. EX: J. Villa
• Arrival mode (EMS, walking, public transportation, etc.)
• Import nurses chief complaint (needed for every level of chart)

• Nurse’s chief complaint is a concise statement describing symptoms.
• **Note: if nursing note differs from what patient states, address this in HPI. EX: Contrary to triage note, pt denies CP.**

[HPI]

• Story from pt/what the pt tells us
• Provider asks questions to get clearer picture about what is going on
• 5 components to HPI:

• Pain

• Y/N Pain
• Location: Location of pain
• Pt may point to the area EX: abd pain but points to the suprapubic area
• We need to be watching the pt as they describe their story to see if they identify anywhere significant to the HPI with body language.

• Quality

• Type of pain the pt is experiencing (description of pain)
• Pain can be described as: sharp, dull, achy, throbbing, burning, pressure, etc.
• If pt uses a word that isn’t a medical term, ex: pain like “fire” or “a knife”, place the words pt uses in quotations. **This will also be a common practice for psych pts. **

• Radiation

• Where does the pain radiate (travel) to?
• FYI: pain usually radiated distally from the point of pain
• Ex: back, flank, testicles, shoulders, leg, neck, etc.

• Severity

• Usually a numerical value on a pain scale of 0 to 10: 5/10

• We can use the “other” option to add the numerical value to the POWERNOTE

• Can be measured currently, at onset, and at maximum

• Timing

• Onset- when did it start

• **REMEMBER this needs to be written in minutes, hours, days, weeks ago, etc.**

• Nature of onset (sudden/gradual)

• Constant, waxing & waning (pain always present, but at times worsens and increases in intensity), episodic, increasing, decreasing, resolved, etc.
• **REMEMBER that when a pt uses the word “sudden”, it is a red flag and we need to be paying attention to the provider’s follow-up to their definition of sudden. Ask provider to use this word in the POWERNOTE.**

• HPI modifying factors:

• What makes your pain/symptoms worse (aggravating factors). Ex: Pain worsens with rest.
• What makes your pain/symptoms improve (relieving factors). Ex: Pain improves with rest.

• Associated symptoms:

• Part of the investigation work that the provider does
• Matches ROS **(REMEMBER this means that I MUST read and pay attention to things already marked in ROS)**

• HPI pertinent positives and negatives:

• RUQ pain: +/- GB removal, vomiting, cough, SOB
• Vomiting blood: +/- ASA (aspirin), motrin, alcohol use, h/o liver disease, anticoagulant use, h/o same. ASA, motrin, alcohol are irritants to the stomach and can cause bleeding to the stomach. Ex of anticoagulants: Coumadin/warfarin, Plavix
• Pelvic pain: +/- sexual activity, abnormal discharge, LMP, flank pain, h/o ectopic pregnancies, UTI symptoms
• Headache: h/o SAH, CTD, HTM, photophobia, numbness, weakness, speech difficulty
• SOB: cough, asthma, home oxygen use, fever, cp, h/o CVDZ, h/o DVT or PE, h/o same, recent travel, surgery
• CP: +/- SOB, smoking, h/o CAD (including family members), hyperlipidemia, HTN, DVT/PE

• Dangerous words that I MUST check with provider to use in HPI:

• Severe
• Acute onset
• Sudden onset
• “worst of my life”
• lethargic

• HPI Overview

• P,Q,R,S,T
• Aggravating/Alleviating factors
• Associated symptoms
• Pertinent medical hx
• Other information stressed by the provider
• Know the importance of spell check

• Abdominal Regions

LLQ: left lower quadrant