Retina is a high-volume, fasted-paced field. For a physician with a busy clinical schedule, it can be challenging to manage the numerous responsibilities associated with documentation compliance—but it is crucial.
Properly training your scribes to take on such tasks can save you time, improve patient care, and help ensure regulatory compliance. In this article, I explain why investing in training your scribes and delegating documentation responsibilities is a worthwhile endeavor that can benefit your patients and practice.
SCRIBE TRAINING BASICS
Thoroughly training scribes is a multistep process that involves teaching them about retina findings and conditions with the goal of translating this knowledge into an ability to properly document examination findings, assessment details, and treatment plans. Effective training ensures that scribes obtain the foundational skills necessary for success.
Use a Stepwise Approach
Scribes must first become familiar with your practice’s electronic health record system, especially if it differs from systems they have previously used.
They will then need to learn the specific terminology commonly used in retina care; taking the time to ensure a scribe understands the most common examination findings and conditions is key. This level of training begins before entering the clinic and is often spearheaded by the office manager or physician.
Once scribes are equipped with enough information to get started, hands-on experience is essential to solidify their understanding and build confidence in applying their skills during patient encounters. In our office, new scribes typically start by documenting encounters with patients who are receiving injections. Next, they move on to established visits before finally tackling new patient visits.
Following these steps helps scribes familiarize themselves with the retina, even if they have no previous experience in this specialty, and builds responsibility gradually while providing opportunities for growth.
Foster Accountability
Physician should regularly review the examination notes taken by scribes to assess for accuracy and completeness because this helps to maintain high-quality standards. During the initial training phase, review all notes closely, and provide feedback to ensure the scribes’ growth and development. Informal feedback is typically given by a more experienced scribe or the physician, but one-on-one feedback outside of clinic hours is also vital.
In our practice, formal feedback is primarily handled by the office manager, allowing for open communication during which scribes can share their own feedback and point of view—an opportunity that is essential for continuous improvement of not only the scribes, but the whole practice.
Avoid Understaffing Issues
A full staff allows each team member to focus on their specific role, ensuring tasks are completed efficiently. However, emergencies do arise, such as a sick child or an unexpected absence, so a backup plan is necessary to maintain adequate staffing when staff members are absent. Understaffing can lead to delays or compromised documentation, which ultimately affects patient care.
Cross-training your staff so they can “float” to other roles when necessary is a key strategy to ensure that all essential roles—work-up, photography, and scribing—are adequately covered. When staff members can step into different roles when needed, it helps ensure that the clinic runs smoothly, even during unexpected disruptions.
Create a Positive Environment
The practice’s atmosphere is shaped by its team. The importance of maintaining a positive work culture cannot be underestimated. Friendly scribes and staff can greatly benefit your patients’ experiences and creating an enjoyable work environment helps to prevent staff burnout and improves the quality of work for both scribes and physicians.>
COMPLIANCE AND REGULATORY REQUIREMENTS
To maintain compliance, scribes must stay up-to-date with Merit-based Incentive Payment System requirements and ensure that physicians document all details necessary for billing. They should verify that the chief complaint and history of present illness (HPI) are appropriately addressed in the assessment and plan.
For example, if a patient reports a burning sensation and irritation in the HPI, this should be documented in the examination, assessment, and plan. Documentation of this patient with suspected dry eye may also note punctate epithelial erosions found during the examination, diagnosis of dry eye, assessment details, and recommendation of artificial tears as the treatment plan. Simply put, the notes must demonstrate a complete record of the patient visit.
Scribes must also feel comfortable asking the physician for any missing examination findings to ensure completeness. One way to confirm compliance and completeness is by conducting internal and/or external audits. A common issue identified in this process is cloning notes (ie, copying and pasting notes from previous examinations), which can be prevented with thorough scribe training. Documenting the visit during or immediately after the patient encounter can also help reduce errors in compliance. In my practice, I always encourage scribes to reach out for assistance with challenging notes and ensure they are completed the same day to avoid any delays in documentation.
IN-PERSON VERSUS VIRTUAL SCRIBES
In-person scribes may also be able to take on responsibilities beyond documentation, such as instilling numbing drops, pulling medications, verifying insurance approvals, and enrolling patients in funding programs. These responsibilities are just as important as documentation. Scribes can also often communicate directly with patients about funding updates or insurance denials, which helps to reduce chair time and facilitates smoother conversations when the physician enters the room. While balancing multiple tasks can be initially challenging for new scribes, having support from experienced scribes and the physician can make a crucial difference during training.
Virtual scribes are becoming an increasingly popular solution in many retina practices, offering flexibility and efficiency. Many of the same principles discussed in this article apply to virtual scribes; initial training, accountability, and feedback are essential, along with ensuring compliance through both internal and external audits. As retina care continues to evolve and practice setups change, physicians must adapt. However, the underlying goal of virtual scribes remains the same: providing physician support to enhance patient care.
KNOW THE VALUE OF A STRONG TEAM
Taking the time to properly train your scribes will pay off in numerous ways, such as ensuring documentation is accurate and compliant, reducing stress, and allowing you to focus on patient care. Whether you use in-person or virtual scribes, it is important to recognize that thorough training, accountability, and continuous feedback are keys to success. Because a well-trained scribe team reduces administrative burden and improves overall clinic efficiency, an investment in scribe training is also an investment in both the future of your practice and the health of your patients.
