A Day in the Life of a Medical Scribe – Nikki

Nikki Chang

Because orthopedics is such a well-known medical specialty, you might think that scribing for an orthopedic provider would be a pretty straightforward process. Pain in the knee here, weakness in the shoulder there, end of story. However, it’s actually not that simple. Working with an orthopedic surgeon demands attentiveness and the capability to identify and document subtle aspects of the office visit that most people would overlook.

Elite Medical Scribes prides itself in providing prospective medical scribes with an in-depth understanding of the duties and challenges they will be expected to overcome in these difficult and incredibly rewarding roles. Today, we’ll be describing a typical day in the life of an orthopedics scribe to teach you about the unique responsibilities that these individuals face.

Your Scribing Shift Begins

You arrive at work and check Epic for the number of patients that you will have during your shift. 30 patients. Okay. You take a slow, deep breath and mentally prepare yourself for the day. Once your physician is on the move, so are you. The two of you walk into the examination room, and your clinician quickly introduces both of you to the patient. He then proceeds to get a brief backstory on the patient and the purpose of her visit. As this conversation is taking place, you commit yourself to giving it your full attention to avoid missing any pertinent information that needs to be documented. It is important to grasp key parts of the history of present illness, or HPI, and transcribe it accurately. The dialogue is a bit jumbled and disorganized, but you manage to piece it into a cohesive paragraph.

The provider then begins the physical examination. Because orthopedics is a complicated specialty, the physical examination is quite extensive. Over the course of the exam, the provider will assess the patient and communicate what he deems to be noteworthy or important. Properly processing this information requires the knowledge to understand what the physician is saying and where within the note you need to add his findings. It really is difficult to correctly process the findings if you don’t have a strong familiarity with medical terminology.

With orthopedics, there is usually a diagnostic x-ray done to further deduce the source of the patient’s symptoms. While the physician is explaining what is going on to the patient, it is important to review what you have written in the patient’s chart because this is likely one of the only times that you will have the chance to fix any errors or omissions. You’ve got a lot of patients today, and not a lot of time for waiting around. You are checking to ensure that what you have written is correct and useful. The physician then discusses treatment options with the patient. You quickly shift back into listening mode and transcribe what you hear. Great, you managed to get everything down. The physician gets up to leave, and you swiftly rise to follow him. One patient down, 29 to go.

The Unique Aspects and Challenges of Orthopedic Scribing

Orthopedics is a medical specialty, which means that orthopedic scribes focus very closely on this one specific facet of patient care. This is great in the sense that you don’t have to visit every part of the body for aches and pains, just where the patient is reporting symptoms. Because of this, appointments are allotted a shorter amount of time because they deal with a more focal aspect of the body. However, this also means that you may fall behind schedule at times. As a medical scribe, it is important to quickly and consistently document accurate information into the medical note. If you fall behind, it’s difficult to catch back up.

Documenting pertinent material is a job that requires advanced multi-tasking skills. Over the course of each patient interaction, you’re constantly typing while listening for and processing new information. In the middle of the physical exam, the patient may have forgotten to mention that she has a history of injury to the left knee, which is important to note in the HPI, so you must go back and enter that information as well. And while you’re in the process of doing that, you also need to make a mental note to look over the data on her previous office visits and blood work. You’re also checking for new prescriptions and making sure that your note matches what was said and performed in clinic that day.

Do You Have What It Takes to Work as an Orthopedic Scribe?

Despite how challenging the process of quickly and accurately completing all of these tasks can be, it’s far from impossible. All you’ll need is time, training, and a phenomenal commitment to your role to gain the skills, alertness, and independence needed to meet the documentation requirements of your assigned clinicians. Once you have these qualities, you’ll be able to succeed as an orthopedic scribe!

Nikki Chang
Medical Scribe at Fairview Clinics

Contact Elite Medical Scribes Today

If you have any questions about Elite Medical Scribes or want to learn more about what it’s like to work as a medical scribe for a particular specialty, then be sure to call or message us today! You can also reach out to us if you’re interested in applying for one of our medical scribe positions in your local area! We look forward to hearing from you.

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