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Scribes In The Urgent Care

Neda Frayha, MD and Sam Ashoo, MD
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The use of scribes in medical practices has been around for decades. They have been utilized in emergency departments, primary care practices, inpatient medical teams, and specialty practices. The use of scribes in the urgent care can be a big improvement to the practice if the implementation is correct. Sam Ashoo discusses with our team his thoughts on this implementation.

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Mike W., MD -

This comment if from Paul Lane, PA-C
Sunday, March 3, 2019 at 10:00 PM GMT
I am writing in hopes of getting an opinion from the UrgentCare Rap hosts on the following situation. Sorry for the long winded explanation of my predicament.
The company I work for uses transcription for each patient encounter. We also use a very dated computer system to run through and select protocols and the appropriate diagnosis. The chief complaint, vitals, lab, xray and final diagnosis are in the record at the end of an encounter. Once the transcriptionist has entered a providers dictation it will be visible in the record within a day or two. Its a multistate 75 center company so there are a huge number of charts to transcribe on a daily basis. Occasionally a visit will not be dictated at the time of an encounter and it won’t show up in the providers dictation que for as much as a week or two. By that time I may have no recollection of the HPI, ROS and Exam for that patient but am required to dictate the visit. If its a straight forward URI or UTI
I can dictate a generic visit. However, if its a more complex visit with abnormal vitals and I don’t remember any details of the visit its a big problem. Its not ethical to make up the encounter. I doubt saying I don’t remember the visit would afford me any legal protection especially if there was a bad outcome. Any suggestions would be appreciated.
I also want to thank HippoEd for putting out an amazing product. I’ve been a PA for 18 years and UC Rap is absolutely exceptional.
Sincerely,
Paul Lane, PA-C

Mike W., MD -

Thx Paul,
You are right that getting things entered at the time of the encounter is super important and I am aware of several legal cases where info was entered later after a bad outcome was found, to the detriment of the provider. Sounds like this is an operational issue which needs addressed. If there is additional info which needs added and if it is truthful, certainly make sure the entry is date and time stamped and record additional memories of the encounter. But the best scenario would be to ensure that info is documented contemporaneously!
M

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Bun (Not) In The Oven Full episode audio for MD edition 185:18 min - 87 MB - M4AUrgent Care RAP March 2019 Written Summary 360 KB - PDF

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