Not too long ago, the job of a scribe was to merely hold the patient's chart, hand it off to the physician, "blend like wallpaper" during the exam, and then escort the patient to the check-out or optical dispensary.

Over the past few years, however, the position has grown to encompass a wide variety of responsibilities.

In our practice, scribes are now responsible for ensuring the completion of everything on the chart -- from the insurance form to the encounter form. They have full knowledge of each patient's examination, and are able to anticipate and competently respond to requests from the physician. They've helped us increase patient flow and patient satisfaction, and significantly decrease physician time in the exam room.

Here's a detailed look at how scribes benefit our practice, and how you can achieve similar results.

Setting up for the exam

Everything the scribe does is intended to increase the quality of the exam, while decreasing the amount of physician time required to perform the exam. The scribe's first step toward this goal is to greet the patient in the waiting room or dilation area and escort him to the exam room. After assisting the patient into the chair, the scribe begins preparing the patient for the exam and setting up the room. This includes:

�        making the patient comfortable

�        moving the doctor's stool next to the counter

�        checking the patient's pupils with the slit lamp or transilluminator to ensure the pupils are completely dilated

�        removing the patient's glasses if he isn't too myopic or hyperopic

�        arranging the dictaphone recorder, referral slips, visual field tests and any other papers on the counter

�        performing additional measurements, such as cycloplegic refraction, A-scan, and potential acuity meter (PAM) if indicated

�        rechecking intraocular pressure if it had been elevated prior to dilation

�        preparing the patient for further tests, such as gonioscopy

�        giving the patient an estimate of the waiting time until the physician will enter the exam room.

Evaluating the chart

Next, the scribe evaluates the chart. Our scribes are trained to "think like the doctor." Their primary objective when reviewing the chart is to make sure that the doctor isn't going to have any questions when he looks at it. They look for:

�        the date and insurance stickers, such as Medicare

�        proper documentation for insurance, referrals and consultations

�        previous exam findings.

The scribe also makes sure that the patient has followed all treatment recommendations from the previous exam. For example, if the patient was instructed to start Pred Forte q.i.d. last week, the scribe will ask the patient if he took his medication as instructed.

At this point, the scribe also evaluates the technician's findings, which were recorded prior to dilation. If the scribe finds any inconsistencies or if information is missing, such as visual acuity or intraocular pressure, the scribe will consult with the technician. This saves the doctor from having to track down a technician during the exam.

Another key function of the scribe when evaluating the chart is to record any previous clinical findings that are unlikely to change, such as a corneal or macular scar, to the current exam. This enables the doctor to quickly scan pertinent clinical information without having to flip through the chart.

Scribes also look out for coding errors when evaluating the chart. This involves:

�        noting order of diagnoses and ensuring they're documented properly

�        making sure management options are documented and pulled forward

�        filling out the billing slip

�        making sure the level of examination meets the criteria needed to meet that level

�        checking that all procedures performed are documented, such as refraction, gonioscopy, and fundus photography.

Assisting the doctor during the exam

Before the physician enters the examination room, the scribe gives him a brief overview of the pertinent history, such as "4-month follow-up glaucoma, pressure and vision stable."

The scribe's role during the exam is to make the time between the patient and the physician as valuable as possible. Except for a brief review of the patient's medical history and signing his name in the chart, the physician is free to have a friendly conversation with the patient and examine his or her eyes without having to lay a hand on the chart.

During the course of the examination, the scribe performs the following tasks:

�        watches for an indication from the physician to place the patient at slit lamp, then adjusts the patient's head, turns on the slit lamp and releases the lock

�        conveys the previous findings to the physician

�        updates the chart with any new findings

�        makes notations such as "better," "worse" or "same" next to the appropriate diagnosis based on the findings

�        documents any relevant conversations.

Our scribes are trained as technicians as well, so they might also perform refractions, fundus photography, visual fields, and even assist with minor surgery upon request of the physician.

Once the examination is complete, the physician briefly reviews the chart, discusses his findings with the patient and answers any questions the patient poses.

After the physician leaves the room, the scribe answers any additional questions the patient has about the exam and provides patient education material. Then, she escorts the patient to check-out or optical, and introduces him to the next patient representative.

The rewards

We started out with one scribe on staff 7 years ago. But it wasn't until 4 years ago, when we increased the level of responsibility to what we've described here and added two more scribes (one for each exam room), that we really began reaping the benefits.

The biggest rewards have been:

�        our patient load gradually increased from approximately 50 patients a day to approximately 90 patients a day

�        our patients' perception of the quality of the care we provide has improved

�        we've increased the quality of the physician's time.

Our patients used to complain that the doctor seemed "rushed," but since we began using scribes more effectively, we don't hear that as often. They usually feel as if he has plenty of time for them, and he does.

Who Makes a Good Candidate For a Scribe?

Technicians are often the best candidates for scribes because they already have a solid knowledge of refracting, optics and general ophthalmology, and they already understand what a technician does so they can pick up on errors.

The candidate you select should be someone who is attentive and willing to learn, someone who is able to instinctively know what you're going to do, and someone you enjoy working with.

Dr. Patterson specializes in cataract and refractive surgery at Eye Centers of Tennessee. Vickey Hawkins is the center's cataract surgery coordinator. She is also a scribe and a certified ophthalmic assistant.