Today, I had the wonderful experience of training a new scribe. With the company I work for, after classroom training new scribes are then started out on the floor. Today was my first day as a trainer and I prayed I was helpful to my trainee. It was a nice experience to be reminded of being a new scribe and learning about how to document patient-physician-interactions. After working in my position for the past 2 plus years, sometimes, I forget that what we do can be daunting, especially on a Monday.
Typically Mondays are like the quiet before the storm. Today started out nice and slow and then after one hour in typical Monday fashion, the ED exploded with patients. In a ten minute span, literally 15 patients checked in. Our little reprieve of taking our time charting and showing cool shortcuts of the system was over.
We began seeing patients back to back and let me tell you, training someone else really makes you aware of what can be improved with your own charting. The whole shift, I was hyper aware of the fact that I was being watched. Now regardless of who you are, if you’re reading over my shoulder, I will typically do a lot of spelling errors. Other then that though, the trainee began asking question about things that are typically second nature.
For instance, the electronic medical record we use only allows us to open three charts at a time. Sometimes a physician will have 4 or more patients waiting to be seen which just so happened in this case. My trainee asked how do I keep organized and I told her staying focused on the task at hand will help you stay organized.
This day also happened to be the day I learned a very valuable lesson about hitting the save button. Typically, i don’t save a patients chart until I discuss with the physician the what the proper symptom was that brought the patient into the hospital. Our medical records is symptom based and in order to open a chart on a patient, you have to input a specific symptom. Since time and time again I’ve had to open multiple symptom charts because the patient told the triage nurse one complaint but and then told the doctor a completely different story, I just don’t save charts until I am sure.
Well today it finally caught up with me and it just so happened I explained this very logic to my trainee before we went to see the patient. Right after leaving the patients room, the medical record system crash. You would not believe how quick my blood turned cold and I began to sweat with fear. I told my physician what had happened and he if looks could kill……You see the patients room we just left was a very complicated patient and the story alone took almost 15 minutes to chart accurately. This may not seem like a long time, but when you’re in a patients room for longer then 10 minutes, the patient typically has an extensive medical history along with a not so simple reason as to why their in the emergency department.
To make matters even worse, my physician had just dictated the most complicated physical exam I had ever documented. So to say I was scared the chart was deleted forever is a complete understatement. Not to mention really embarrassing since this happened in front of the trainee. After 8 of the longest minutes of my life thus far, the system was back online. I quickly clicked into the patients chart and prayed at least some of my document was saved. When I clicked into the existing files tab and saw my name next to a pending chart, I thanked the Lord and my heart filled with relief. I clicked restore as quickly as the mouse would allow and hit save all in the span of 2 seconds. Looking at the chart, the only thing that did not save was the physicians preference which is easy to replace since every physician has a favorites template for exams.
After I completed the note making sure to hit save after each section was completed, I turned to my trainee and we both laughed.
Like I said, being a scribe trainer is a very humbling experience.