Sacramento Sutter Physician Preferences

Hi Sac Sutter Scribes!

Please post all Physician & MLP Preferences under this thread. Hoping it will be helpful in getting accustomed to the various clinicians. Thanks!

Carla

(From Chris)

Working with Dr. Zacharias this evening was exciting at times and was overall pretty fun. Dr. Zacharias is very good with patients. He developed rapport quickly with patients. He displayed patience and good nature during each patient interview and was complimented by more than one patient for being a kind doctor.

Dr. Zacharias does move about quite quickly and keeping up with him was a challenge. He threw physical exam and lab findings at me in bunches, and I had to ask him to repeat himself quite often. Despite this, he was always willing to repeat himself without being ever being short about it.


Even though Dr. Zacharias moved quickly, I never got overwhelmed because we developed a good habit of going over each chart after he had a chance to place orders immediately after the patient interview. He would quickly add anything else he wanted in the chart so I made sure to pay close attention. He would then add his differential and sign a few lines. This immediate feedback helped us develop a solid communication style that I think would be good to emulate.

Dr. Zacharias also let most all patients know that I would stay back and ask a few questions and I took the liberty to fill out just about every chart to level five requirements. Dr. Zacharias did a thorough job of covering ROS by himself though. Often in the interest of time I would go straight to ROS to document findings that were being asked as associated signs and symptoms and a lot of my charts could have benefited from going back and adding a few particularly pertinent positives and negatives to this section of the HPI.

Dr. Zacharias did not utilize the chart for XR interpretations that he performed by himself. Instead he entered an interpretation on the PACS system itself and then printed the interpretation statement to be attached to the patient's chart. He bypasses the scribe on this step.

In order to get Dr. Zacharias to feed me lab interpretations required that I bring it up explicitly and then he often gave his interpretations quickly enough that it would be difficult for me to capture the first time around. I had to ask him on most occasions to repeat a specific part of the results and he was very amicable towards this end. Not once was he anything less than appreciative to have me there helping out.

(From Oscar)

My shift with Dr. Zacharias went smoothly, and I think Chris helped much with getting him used to having a scribe. He can be quick at times, but is nothing overwhelming, as eventually you have the downtime to catch up. Once he picked up a patient, we went over triage notes, and EKGs. Once in the room he was very good about getting a full ROS, and a full exam. If he missed questions, he would allow me to stay to ask for more ROS systems. On the exam itself, he called out anything positive, and the rest was to be assumed negative. His normal exam is as follows.

Constitutional: WDWN, No distress
Skin: Normal hydration, dry
Head Ocular: PERRL, EOM’s intact
Neck: Normal anatomy, full ROM, no meningismus
Resp: non labored full sentences, no retractions, normal breath sounds
<3: Normal heart sounds, no edema
GI: no distension, no tenderness
M/S: Full ROM, both upper and lower extremities
Neuro: A&O x3, motor normal
Psych: A&Ox3, memory x3

Of course we know this is the case if he checks on lungs, heart, etc..

Typically while I was filling out one half of the chart, he would fill in his MDM section. I would then hand back the chart completed, once it was time for discharge/admit. It seems as he is now getting more used to having a scribe and will work well with you. The shift went smoothly, and was even better due to his great selection of music. I don’t think anyone will have much difficulty with his style.

(From Roma)


Today, I worked with Dr. Feinauer who was an absolute pleasure to work with. He is thorough and has great bedside manner. Considering that today was the first shift for us together and especially for him working with a scribe for the first time, he did a great job sharing everything with me, he was also slow when he verbalized the exam which was great in the beginning when I was still becoming acclimated to locating where everything was on the chart. Also, Dr. Feinauer does not mark off PERRL unless he does it, he does intermittently mark off EOMI without doing the finger test.

The one major problem that was mainly on my part was that I was under the impression that everything needs to be documented in the small "Treatment in ED" space which I was told was not the case since there was an "Emergency Clinical Record" which was actually almost exactly what we wanted to achieve in our addendum. The confusion was namely due to the fact that right next to where it said "Treatment in ED", it was explained that all meds need to be documented on the small three lines with time and dosages; to amend that situation, maybe if we can write in little line or apply a sticker that can be used to direct the reader to "Emergency Clinical Record" then the three precious lines on the T sheet can be used to explain the doctor's thought process, i.e. time: fever reducer ordered, time: patient with vomiting, labs, IVFs and anti-emetic ordered, time: patient feeling much better, case discussed with PMD, patient okay to be discharged and instructed to follow up with PMD in office.

Some other concerns included who would ultimately complete the MDM portion of the chart because I was not introduced to the workings of Shipper until past mid-shift which would be nice to have as it reduces the bugging that you have to do to get that portion of the chart done (a lab value course explaining the meanings and normals would be very helpful and even necessary to complete the returned lab portion of the T sheet).

(From Steph)

Dr. Nations was great to work with. He was wonderful about introducing me to every staff member we came across which made me feel even more welcomed. The ER staff was also very excited to have scribes (a few nurses asked why they couldn't have a scribe . Here is a run down of how Dr. Nations and I worked together today. He would sign up for a patient, we would locate the chart and then review the triage notes. Dr. Nations would state the pt's PMHx the nurse obtained and I would document it on the chart (also trying to get vitals on the chart at that time as well). We would see the pt, and discuss the case after. He would write orders and then onto the next pt.

Dr. Nations and I established the 'ideal' Doctor-Scribe interaction for charting HPI, ROS, and the physical. I told him from the start that the easiest docs to work with are the ones that verbalize the positive PE findings while preforming the exam and then anything touched/looked at/listened to with nothing said about it was considered negative. Dr. Nations took my advice and ran with it. Every patient we saw today he called out the positive findings in the room and the rest of the exam I would document as normal (several pt's I had to prompt him afterwards about abdominal tenderness or extremity tenderness and he would tell me after prompting). We would reconvene after seeing the pt, and run through the chart together reviewing the HPI, ROS and the PE. If we didn't have 10 ROS he would allow me to run back into the room and ask a few more ROS questions to get the 10. Dr. Nations was great at asking about 8 ROS on his own (Fever, chills, vision changes, cough, congestion, chest pain, N/V/D, headache, problems urinating are his usual 8 ROS questions). We obtained most of the PMHx from the nursing triage notes and would double check with the pt for correctness. Dr. Nations on occasion got Social hx but if he didn't I would run back into the room so I could get 2 of 3 for PMSFHx. Dr. Nations stated he rarely ever asks Family hx, only gets it if the pt verbalizes it by his or her self.

Here is Dr Nation's Physical Exam: Under constitutional he likes things written as 'elderly female' or 'overweight male' to be written along with WDWN checked if it applies. Skin was a 'gimme' unless he state otherwise. He always used the light and looked at pt's eyes so PERRL, sclera and conjunc can be checked normal. For ENT he always looks in the pt's mouth so check all that applies to the mouth/pharynx. For the neck he always checks for adenopathy, and has you check supple, without menigismus. We had an uncooperative pt today and he wasn't really able to asses the pt's neck (given the pt was trying to bite and actually did bite the doctor) and under neck he had me write 'actively' for active ROM. Heart and lungs check what applies for heart and lung sounds given he always listens to the them. Under cardio you can also check normal pulses then circle lower because he always checks femoral pulses. also no peripheral edema because he always checks for that. GI he likes 'full and soft' written in on most pt's, if they are obese he wants 'soft and obese.' Can also check non-tender, non-distended unless stated otherwise. Most pt's he checked for CVA tenderness so you can check no CVA tenderness under both GU and M/S. Under M/S check non-tender extremities and full ROM. For Neuro he likes A&O x 3, normal symmetric and motor and sometimes requested CN's checked. Psych check A&Ox 3, memory normal, and grooming.

For MDM, labs, xrays, EKG's etc there was a bit more struggle to obtain this info. When I could I would hop onto the computer Dr. Nation's was using and get into SHIPER (or whatever the heck its called) and put abnormal lab findings and try to get past medical records. I asked Dr. Nations about how to chart labs and he basically told me not to worry about documenting them. Towards the end of my shift with some nudging I was able to get him to go through labs with me and I'd write the abnormal findings. Same goes with the EKG's, for the most part he was just writing the interp on the actual EKG but towards the end of the shift I got him to give me a few EKG interp's so I could put them on the chart. At first he told me he would do a dictation for all his MDM on pt's but towards the end of the shift realized how having a Scribe will really help him cut down on the dictation. After every phone consult I asked him who he talked to and what was discussed. I think at first Dr. Nations just thought I was being nosey but after seeing my charts with all the consults on them he realized I had a purpose and was really impressed with the consults being documented. For differential diagnosis, he would usually give them to right after we saw the pt or when we were preparing to discharge them and were putting in the pt's diagnosis.

(From Chris)

Dr. Boren was a pleasure to work with this evening at Sutter General. This was his first time ever working with a scribe. I laid out the basics for him in about a minute before we started seeing patients and I just started right out with the first chart. The primary focus of my pre-shift message is that whatever you verbalize to me, is whatever you want to guarantee to be in the chart, and that the more we talk, the more I will be able to follow along and feel confident. I let him know that I will also parrot back findings to both confirm findings and to let him know how much time it takes for me to enter each piece of data as he is feeding it to me.

Dr. Boren is a total natural with a scribe. He fed me every normal and positive during the physical exam which made it a snap to have everything in there. He let me hang back with the patient to ask ROS questions and some Social History while he added orders to the chart. I really had to stay on my toes because we charted about 18 patients and sometimes we would move from patient to patient without pause. Dr. Boren was so attentive to the needs of his charts and always appreciated when I reminded him about covering something that he might have missed. A couple times I had those moments where I helped him remember a particular detail on the spot, or even help fill out a differential where I got to pat myself on the back.

Here is Dr. Boren's normal, thorough physical exam, assuming full auscultation and relevance (in parentheses are things he didn't always verbalize but was okay with assuming)

constitutional: (WDWN, NAD)
skin: (nml hydration, dry, warm)
head/eyes: Atraumatic, normocephalic, PERRL, EOMI
ent: pharynx without erythema or exudates, tongue midline
neck: supple, FROM, no JVD
resp: lungs clear to auscultation, non-labored respirations
cv: NSR, no murmur/rubs/gallops, normal pulses lower extremities
gi: soft, no distention, non-tender to palpation
extremities: FROM, no peripheral edema
neuro: (AOx3, MAEE)
psych: (normal memory)

Thoughts, Tips and Tricks:
I found it was easiest for me if I made sure to get two patient stickers as quickly as possible to add to both sides of the chart. This was the best way to stay oriented with each of our patient's. I also wrote down in small numbers each patient's room number next to the identification sticker to help me remember, especially since the physician would refer to patient's by room number on occasion.

I have never before been asked to use abbrevations but it is now obvious that shorthand is the only way to fit what you need to in the space provided. This is one reason that watching my physician chart has helped me save space and time.

Dr. Boren looked over the charts when the patient was ready for discharge or admission and the full chart was ready for signature. He basically left it up to me to get in everything I needed and ask him any questions.

I was able to use "Shipper" (sp?) effectively this shift and do a lot more when it came to MDM. He had me write the full differential, consults, rechecks and med responses and most of the dispositions as well.

(From Steph)

Dr. McGough's Preferences:
HPI: for CC she writes "18 y/o male (draws symbol for sex) c/o cough" then fills in location, duration, timing, quality, etc. I followed how she was writing them and she was happy with my HPI's.
ROS: she usually asked a full ROS, but when lacking I prompted her and she went back into the room and asked a few more questions (I told her I could do it on my own but she still asked herself). She checks the box on the left of the system.

PMSFHx: Dr. McGough was great at getting all of this for most patients. If family hx wasn't pertinent then she wouldn't ask

Normal Physical:
Const: WDWN, No distress (she checks no distress for almost all of her patients, but it might be good to ask her distress level on pt's)
Skin: nml hydration, warm dry, no rashes (the usual)
Head/Ocular: No trauma, PERRL nml sclerae/conjunc (always uses light to look at pt's eyes)
ENT: MMM, normal pharynx (always looks in mouth)
Neck: normal anatomy, suppple, no andenopathy
Resp: normal anatomy, non labored..., no retractions..., normal equal...
CV: no murmur..., normal pulses
GI: no distenstion, nontender
M/S: normal ROM UE and LE, sometimes does CVA
Neuro: A&O x 3, normal motor
Psych: A&O x 3, memory normal, normal grooming

Labs/Xrays: wants all abnormal labs written in, circle normal labs. Xrays were all read by radiology so no problem there
DDx: she would give these to me either when discharging or after seeing the pt
Reevals: she reevals pt's prior to discharge. likes VSS, ambulatory. I also put whatever she discussed with the pt and pt family and she liked that.
Dx: she will give you the Dx to put in, likes stable circled under condition, dispo (admit, discharge, etc) checked, and aftercare discussed if she discharges the pt
Discharge papers: on occasion she had me write the discharge instructions. Usually had me put: Rest at home, take Rx as directed, f/u as needed and return to ER if concerned. then put the Dx.

(From Roma)

Dr. Troung is very fast and because he is the only provider on at night has developed an organized system of keeping track of everything. When he first got to the ED, there were approximately 10 people waiting to be seen and we saw those in the first 2 hours without taking a single second to sit down. Because of the fast pace that he worked at, it was just not possible for me to stay behind to ask any ROS questions.

His normal exam is:

CONST: WDWN
SKIN: No decubitus ulcers, no significant lesions, rashes
HEAD/OCULAR: PERRL; normal Sclerae/Conjunctiva, EOM's are intact
ENT: Moist Mucous Membranes/Tears, Normal Canals and TM's, Nares Patent; Sinuses Non-Tender, Normal Pharyxn, Uvula Midline
NECK: Supple, without Meningismus, No Adenopathy- Thyroid Normal, no JVD
RESP: Non-Labored, Full Sentences, No retractions or nasal flarem Normal equal and clear BS x 4
CV: Cardiac: No Murmur/rubs/S3, Normal pulses: upper/lower, normal cap refill, no peripheral edema
GI: No distention, normal bowel sounds, no bruits, no organomegaly/masses, Non-tender palpation/percussion, (ALSO, always checks for McBurney's)
GU/GYN: No CVA percussion tenderness (which he normally checks and only if he checks) but does likes to call out PSIS?? (in M/S) if checked
M/S: Non-tender spine/CVA/back, normal upper and lower ROM
NEURO: Normal and Symmetric Motor. Normal Sensory, Normal and = DTR
PSYCH: A&Ox3, Memory x3, normal grooming, no hallucinations/paranoia, no thoughts/plan self harm.

Now on to the MDM, like I mentioned earlier, being that Dr. Troung only works nights, he developed a system to keep track of everything. I let him do most of the MDMs while looking on to see what he was marking off as normals and what he liked to document. On his labs, he does not like to circle things, so he writes WNL over the line running down for the lab, and if a lab is negative, he writes the value in and either writes WNL or leaves the rest of the column blank.

(From Chris)

Dr. Crawford and I had a solid shift together today. Dr. Crawford is another doctor who adapts naturally to working with a scribe. From the outset she was introducing me to patients and making me feel like I was working as part of a team with her and the other staff of the ED.

Dr. Crawford didn't mind calling out full physical exams to me and doing so in a way that did not have the patients questioning what she was doing. She would use her discussion with the patient as a means of communicating indirectly with me. This both made the patients feel like they were getting a full education but also gave me a chance to highlight and structure information so it was appropriate and accurate for her charts.

One of the best things Dr. Crawford did was to review each patient’s nursing chart with me before walking into the room. She would pull out the doctor's chart when provided by nurses (with 4 identification stickers) and quickly jot down the vital signs including pulse ox for each patient. Then we would discuss some past medical history, sometimes looking it up on the computer first. This would ensure that I was entering almost every patient room with a fully prepped chart. This kept from getting to hurried and I was able to easily focus on the patient interview.

Dr. Crawford's physical exams had a lot of variation between them and were typically very specific of the presented case and differential diagnosis. There were, however, a few noteworthy findings that she often wanted included in her physical exams:

constitutional: distress, appearance (including grooming)
skin:
head/eyes: pupils reactive and accommodating
ent: trachea midline, moist mucous membranes
neck:
resp: lungs clear to auscultation, non-labored respirations
cv: heart sounds, pulses, edema
gi: soft, non-tender to palpation, good bowel sounds
extremities: FROM, no peripheral edema, sensory
neuro: arousal level (awake), speech (clear), (no) facial droop
psych: memory, grooming

(From Steph)

Dr. Nguyen was great to work with amongst all the chaos in the triage area. Thankfully, Dr. Nguyen was very easy going and she is excited to have scribes. We had a brief chat about how having scribes will hope the flow of the department.

Doctor Preferences: She was really good about not only stating positive exam findings, but also stating negative exam finding while examining the pt. She pretty much gave me the entire exam while in the room, it was great! Not a whole lot to report on her exam preferences. Dr. Nguyen's exams were all very different for every patient given we were rapidly assessing some pt's, other pt's she did full exams on, and others she did focused exams on. Here are the few common factors I found her calling out on exams:
Const: WDWN
Skin: warm, dry
ENT: moist mucous membranes, pharynx normal (if she checks the mouth)
Neck: usually always checked for lymphadenopathy, supple
Resp: non-labored, full sentences. no retractions. clear breath sounds (if she listens)
CV: No murmur, Normal S1/S2, no S3/S4. Usually checked for edema
GI: soft, non-tender, no rebound
M/S: no CVA tenderness, no spine tenderness (if she checked the back she would check for both CVA and spine tenderness). FROM of UE and LE (gimmies for her)
Neuro: Alert, moving all extremities
Psych: alert, normal grooming

For MDM she would dictate this to me and really liked that I was able to write neatly and small enough to fit any MDM stuff in. She would also give me DDx. For Labs/Xrays I was getting most of this info myself, and for labs writing in the abnormals. Dr. Nguyen gave me EKG interpretations (and I introduced to her the need for 4 elements to be documented for billing and she was very thrilled that I was able to tell her when she needed more elements so it could be billable).

For ROS she was comfortable with me going back to talk to the pt to get full ROS questions. Dr. Nguyen was good about getting past medical hx, social hx, and family hx in the appropriate cases (ex Chest pain). Dr. Nguyen always wanted 'See Triage Notes for Meds/Allergies' checked. She also had me write up discharge papers for some pt's. She likes "Follow up with your primary doctor as needed (or in 2 days if they need specific rechecks. Return to ER if worse or concerned." and would give any other specific things when needed.

(From Laura)

Dr. Gordon and I worked really well...we complimented each other. Dr. G appreciates reminders!!! I won him over by being his eyes and ears. Even though he appreciated the charting and really enjoyed having all that information, all he really wanted was for me to stay on top of him.

His charting style:
-He is really open to go over the chart with you at anytime. He doesn't mind questions. He really appreciated me showing him the chart after seeing the patient because having a visual really helped him remember.
-After seeing the patient he would clarify what he wanted on the ROS. I never went back to the patient's room to ask questions. Even though he doesn't mind, he didn't find it necessary.
-He is not very focused on the PMH or the Social History. He did ask questions but I found out more through the nurse's notes. Once I brought it to his attention he would sometimes go back into the room and get more information (which he did often because he realized that he didn't ask enough questions to create a complete chart)
-Physical: I explained to him that telling us the abnormal findings in the room was very helpful for us, so he calls abnormal findings in the room. He did expect me to check of "normal findings" but I again tried to get him to verbalize his findings. I want to make sure he understands our scope of practice.

Constitutional: you can assume no distress and WDWN. He likes to point out obesity on most of his patients. He also said you can assume distress level but I would always recheck with him
Skin: on normal exal he likes to check all 3. He will write down scars in his findings.
Head/Ocular: He will check sclerae on most patients so unless otherwise specified you can check all everything besides normal fundi
ENT: on normal exam he will check everything but Normal canals and TMs unless he looks inside the ear.
Neck: on normal exam everything checked.
Respiratory: He does listen to heart and lungs on most patients. But on normal exam where he doesn't listen to lungs, as long as the patient talks he will check normal anatomy and non-labored, full sentences.
CV: He He checks for edema and that will count as cap refill.
GI: he will never listen to belly...so never check bowel sounds. Otherwise he will report abnormal findings
GU: only if checked
M/S: you can assume negative findings on normal ROM if patient is moving around
Neuro: if patient is talking and alert you can assume A&Ox3 and normal cranial nerves. The other 4 neuro findings will have to be dictated by him.
Psych: you can assume all if he calls it a negative exam.

(From Laura)

Dr. Yu came in and from the start was very welcoming and open to the scribe program. He let me chart from the very beginning. He is very fast and efficient, so get ready for fast dictation. He will review triage notes with you and you can fill out the vitals before going to the room. He will also read out PMH and anything else that he wants in the chart. Once in the room at the beginning he wasn't asking enough for the ROS, he got better as we went on. He called out all the abnormal findings for the physical in the room...he does dictate very fast. Once you are out of the room, he will review your chart and will give you the rest of the physical, differential diagnosis, and the MD. He likes to short hand his ED course and will dictate to you. I was filling out the HPI but everytime when we got out of the room he would dictate..."47 yo with Hx of DM presents today with c/o seizure like...." So I learned to just wait for his dictation to fill out the HPI, even though I took really good notes and I would complete the chart quickly after.

He wants PCP and to write "See RN list" under meds on every chart.

On the Physical...he looks at the chart to remind himself of things. So once out of the room he would read out even the normal findings that he wanted checked.

constitutional: he will check WDWN, Not visibly distressed and circle non toxic on normal exam. I know non-toxic is under peds but he still would circle it.
Skin: check all under normal
Head/Ocular: no trauma and EOMs under normal exam
ENT: Hearing intact and MMM under normal exam
Neck: Normal anatomy and ROM and Supple without meningismus
Respiratory: he will read out everytime...if he doesn't check he won't assume
CV: he will read out
GI: will read out only when checked
MS: when he checks for pedal edema, he asked to document it "no c/c/e"
Neuro: A&Ox3 and normal cranial nerves on normal exam
Psych: will check only on psych patients.

Overall it was a great shift, definitely one of the fastest dictators that I've worked with at Sutter. He is young and super efficient. Luckily, our shift was not busy to start but I can see that once its busy he can go super fast. He only dictates critical patients. The great thing at the end was that he was using me for getting charts and relaying messages to the nursing staff. So he really saw the use of having us around not only to remind him of diagnostics but also for helping him get charts and increase communication with the staff.

(From Laura)

Dr. Foley and I got off to a slow start this morning my "white cloud" effect which turned out to be really nice for my first shift at Sutter Memorial. We went nearly 2.5 hours without seeing a patient and it gave us a great chance to tour the ED and to review Dr. Foley's charting strategies and preferences in great detail.

Dr. Foley likes to have charts prepared with vital signs copied from the nurse's triage notes prior to entering patients' rooms. This helps him to review changes in vital signs when performing re-evaluations later in each patient's visit.

Dr. Foley goes through a thorough patient interview at the bedside. He is used to hand-writing charts at the bedside so he has a systematic approach to covering the elements of the chart. He also transitioned well to verbalizing findings in the physical exam and after reviewing the charting process with me and seeing a few patients we were able to get nearly the full HPI, ROS and PE completed before leaving the room.

Dr. Foley still completed most of the MDM at the beginning of the shift by himself but gradually by the end handed me more and more documentation responsibilities.

Physical exam consistencies:

constitutional: WDWN, NAD
skin: normal hydration, no lesions no rashes
head/eyes: no trauma, EOMI, (PERRL if looks into eyes)
ent: MMM
neck: normal anatomy and FROM, no adenopathy
resp: normal anatomy, non-labored full sentences, no retractions or nasal flare
cv: (don't assume heart sounds, edema if not auscultated)
gi: (don't assume tenderness if not palpated, or bowel sounds if not auscultated)
extremities: normal range of motion upper and lower extremities (if mentioned)
neuro: A+Ox3, cranial nerves normal as tested
psych: check all under normal exam

Additional preferences:
Place treatments PTA (en route) on last two lines of HPI space.

"See triage note for meds and allergies" on all charts

"under my supervision" from the MDM section on every chart

Time stamp each re-evals and consult

Keep an additional patient sticker for his own patient HPI tracking system

Dr. Foley does like to dictate most labs, XRs, and EKGs

Dr. Foley has a wonderful personality. He is very open and loves feedback. He has great bedside manners and is very thorough.

Last night's shift was the ideal scribe/doctor efficient shift IMO. Dr. Feinauer seemed as if he had worked with scribes before, as the entire shift went smoothly. I'll get straight to the point, as Roma had a good description on what a shift with him is like. The following are his normals:

Constitutional: WDWN, No distress

Skin: Normal hydration, dry

Head Ocular: PERRL, EOM’s intact

Neck: Normal anatomy, full ROM

Resp: non labored full sentences, normal breath sounds

<3: Normal heart sounds, no edema, equal pulses, (circle both upper and lower)

GI: no distension, no tenderness

M/S: Full ROM, both upper and lower extremities

Neuro: A&O x3, motor normal

Psych: A&Ox3



These are for the most part his normals, and a few others which we can see when he tests, such as the neuro exams, etc... Either way, he will call out his normal findings as well as the positives.

Overall this was a very productive shift, and he seemed to be pleased as things were going smoothly and quickly.

From Oscar:
Once entering the pt's room, she very good on calling out her physical exam. Negatives, and positives were being called out which was great as it made the chart more complete. We later discussed what she was comfortable with on her normals, which Stephanie had pointed out already. She was comfortable with me getting the complete ROS after the visits, and even before the visits, while she got other stuff done. All radiology results and labs were easily accessed and entered. I completed most of the chart, but she still dictated the MDM section, even though I had entered differentials, final diagnoses, etc.. She explained that she feels there is very limited space on the T sheets, and feels that she also needs to elaborate more especially on higher acuity cases. One thing she does want us to work on is keeping the chart available to the doctors at the time of consults, as she did consult doctors, while she had sent me to ask pt's for other information, or other tasks, and I was not aware she was on the phone. I was there for several consults, but on others, I was doing other tasks, and still had the charts, as they still needed to be completed (labs, complete ROS, workups, etc..). Using the EPIC, system is another thing we discussed, and may be very helpful in retrieving information about a pt, prior to visiting them. Overall this was a very good/improved shift, and Dr. Nguyen did very well using a scribe efficiently. She was very surprised as I was speedy and handing her stuff she needed at the exact moment (almost like reading her mind lol). Especially during consults I would run to give her the chart of the pt she was speaking of, which was a big help to her.

From Roma:

I began working with Dr. Ritz who had worked previously with a "pseudo-scribe" which was not a good experience for her and was worried this shift would entail similar challenges. I made sure to tell her that we would only be documenting things that she wanted to document because this was her chart. Also, Dr. Ritz wanted me to tell her exactly what we should do because she only dictated prior to working with me and was not even familiar with the paper chart. Dr. Ritz was alright with me going back to get ROS, but she preferred me to not because of liability issues, and said she does not like to document every concern that patients bring up in the ROS, so she completed that part of the chart.

Dr. Ritz's normal exam is (and she verbalizes most of the exam): (put all vitals from the nursing notes on the top of the page)
CONST: WDWN
SKIN: Normal Hydration, dry, warm
HEAD/OCULAR: PERRL; normal Sclerae/Conjunctiva
ENT: Moist Mucous Membranes/Tears
NECK: Supple, without Meningismus
RESP: Non-Labored, Full Sentences, No retractions or nasal flare, Normal equal and clear BS x 4
CV: Cardiac: No Murmur, RRR
GI: No distention, normal bowel sounds, no bruits, Non-tender palpation/percussion
M/S: Normal upper and lower ROM
NEURO: A&Ox3, Normal and Symmetric Motor
PSYCH: Normal grooming

Overall, Dr. Ritz and I had a good time working together, and she is definitely receptive to the scribe program even considering that she is so used to dictation, but the effectiveness of the shift cannot be gauged well because we only saw 11 patients in the 6 hours that I worked with her and basically sat around for the last 1.5 hours waiting for labs to trickle back. Dr. Ritz's did say several times that she thinks that the program is going to help a lot because she has an extra set of eyes and ears and "all this extra help" now for documentation.