The disturbing confessions of a medical scribe

The disturbing confessions of a medical scribe

As a medical scribe working with a large, well-known scribe company, unnamed to protect my job, it makes me proud reading all the articles published about how much having a scribe benefits a physician, especially in the emergency department. I enjoy my job immensely and I am grateful for the opportunity to learn and engage in patient care. However, as a pre-medical student working next to several other doctor-hopefuls in a high stress environment, being a scribe frustrates me on an ethical level.

Let’s examine the structure and reasoning that has made medical scribe programs so successful. When EMR systems were first introduced, there was resistance, but it gave way to the push for efficiency. The biggest benefit of EMRs is easy: risk management. By allowing for documentation of every little part of a patient’s care, EMRs significantly decrease the risk of mistakes slipping through the cracks. It allows for better defense of the physician’s medical decisions, even months down the line.

For example, a physician I worked with was asked to go to court for a patient who had been assaulted by her boyfriend. The patient had been seen several months ago in the ED. Few physicians would be able to remember all the details of an encounter so long ago. His testimony was therefore entirely based on the medical chart, written by me and approved by him. The EMR allowed for comprehensive, detailed documentation of test results, discussions with the patient, and interactions with the police.

Unfortunately, such comprehensive medical records take time and effort to write. Physicians complain that they were becoming little more than data entry specialists, dedicating large portions of the time they should be spending with patients to clicking buttons. In comes the scribe. Usually students or recent graduates interested in becoming a medical provider, we become the physician’s right hand. Scribes are purported to decrease physician burnout considerably and increase ED efficiency. Better documentation also leads to better billing, so hospitals make more money. The physicians I work with, in a hospital who has been using scribes for over 3 years now, have all been grateful for the program.

Sounds great, right? The winning combination of EMRs and scribes. The road to increased efficiency, increased Press-Ganey scores, increased billing accuracy, increased fraud, increased profits for the administration. Happiness abounds.

How many of you missed the “increased fraud”?

Medical billing is based off charting and documentation, and that can have different levels. Level 5 charts are billed the most, when the provider offers the higher level of care. Ideally, EMRs make documentation more accurate, allowing for more level 5 charts for medical coding and billing. But when all it takes is a few buttons to increase your billing, how many physicians submit to small temptations and conveniences?

In Epic’s CareConnect, a widely used EMR, there is a small button that, when pushed, indicates the physician has counselled the patient to stop smoking. It adds a small amount ($20-30) to the billing, and the physician makes a little more.

I’ve been told by physicians, “If the patient is an active smoker, just click that button about the counselling.” Most of the time, the patient is counselled. Sometimes though, they aren’t. But if that button isn’t pressed, eventually, it comes back onto me.

“I told you to press it, so just press it.” At which point, I protest, “But you didn’t counsel them.”

The physician responds, “You probably just weren’t paying attention.” Or “It’s okay, just click it anyways.” As a “good” scribe, I don’t say anything and I click the button.

Similarly, physicians can make “macros” which autopopulate certain parts of the chart, such as the physical exam. It’s nice and saves time, and it is usually accurate. It ensures that there are enough areas input for the physical exam for the chart to be level 5. But sometimes, the physicians don’t do everything their macro says they’ve done. In those cases, I go in and take out the inaccurate information. Sometimes, I’m told to just leave it, that I must have missed when they did it.

How do I know it’s not me? Because as the physician’s right hand, I have been with them the entire shift, even during any breaks they take. I have paid incredibly close attention to everything they say or do so my charts are as complete as possible. That’s my job. I know they did not counsel the patient. I know they did not ask for social history. I know they did not listen to the patient’s heart rhythm or breath sounds. I know every time I “just leave it,” I am lying in a medical document.

I don’t blame the physicians. The pressure on physicians from the administration is incredible. If a physician only charts what they has done, that means their charts sometimes don’t reach level 4 or 5. When that happens too often, administration comes down, and they’re told to write better charts. They lose money when their charts get downcoded.

So what do they do? They click a few extra buttons for that higher level chart, because they’re seeing so many patients in a shift and it’s that much easier to just click a few buttons than double the time in a patient’s room when there are other acute patients waiting. Considering how much debt physicians are straddled with as a result of the insane cost of medical education, it’s clear why that extra $20 per patient counselled is so easy.

These are small, tiny transgressions. In the grand scheme of things, it probably does not matter that that the patient did not actually get counselled about smoking cessation. But small things add up and in the end, the burden of all this comes back onto the patient. More importantly, if thousands of small lies are okay and never brought to light, how many bigger lies are out there, hidden by convoluted billing, poor memories, and a healthcare system that lacks any semblance of transparency?

I will never regret being a scribe — as I prepare to apply to medical school, I know my experience as a scribe will be a core piece of my application. I am lucky to have this opportunity. I am also a person with bills to pay, and I don’t want to lose my job. As a “good” scribe, I understand that the chart I am writing is ultimately a reflection of the physician, and therefore at the end of the day, I will write whatever the physician wants me to write. It isn’t my job to say no. Whether or not it’s my responsibility to is undecided.

The author is an anonymous medical scribe.

Image credit: Shutterstock.com

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  • PamelaWibleMD

    Oh such a sad state of affairs that we accept daily lies as part of the job of a physician. We obviously need to take back our profession and get back to the patient-physician relationship. While I appreciate (though have never used) scribes and EMRs, some of this technology allows us to move at an inhumane pace and that isn’t good for doc or patient (or scribe). Assembly-line reductionist medicine will ever deliver the care people need and it is harmful for docs (burnout, depression, suicide). Let’s get back to relationship-driven care. See (TEDx Talk on ideal care:

    http://www.youtube.com/watch?v=5cvHgGM-cRI

  • LeoHolmMD

    Great, honest article. It exposes how absurd our payment system is. The coding system reinforces the most perverse incentives there are in medicine. So much time is wasted on documentation instead of actually listening to patients. Hypercoding hurts everyone. All payers have to do is reach over and lower the price again. Now you have to see more patients. Providers trying to do honest business are directly harmed by these practices, as are patients. Write better charts? Someone needs to tell your clown administrators to go write better contracts and try honest business for the first time ever.

  • Suzi Q 38

    Thank you for this information.
    I like to order my physician report about past visits.
    I like to make sure I heard everything correctly, and the only way to do that is to order and then review my medical records.

    I think that you should continue doing what you need to do and realize that the reality is that some doctors can and do lie regularly and often.

    At the hospital that you work for, what is the percentage of doctors that ask you to lie and add more services to the EMR that was clearly not done?

    Just curious.

    Welcome to the real world.

  • http://www.barronbrown.net Barron Brown

    I am a physician who helps to design EHR note templates to enable efficient and accurate data entry. I can’t countenance your statement “I don’t blame the physicians.” Who else could possibly be to blame for this commission of conscious, intentional fraud? Physicians know full well what they are doing. Their rationalization is of a piece with the shoplifter or petty thief. This, when most physicians possess a deep and abiding faith in their moral superiority. How do you suppose these doctors would respond if their next restaurant bill was padded $30 because the waiter was busy and it was just too hard to be faithful to the truth?

    Small, tiny transgressions add up to moral compromise. In the grand scheme of things, they matter. Doctors who commit minor fraud with impunity become habituated to lying. There is no excuse.

    • http://www.capko.com Laurie Morgan

      Of course you are correct that the doctors must be accountable, but isn’t the scribe (correctly, I think) pointing out that it is the intense pressure they get from administrators that is leading them to ‘fudge’?

      • uDRAKSh2L5

        And isn’t this, in a nutshell, the reason that for thousands of years the practice of corporate medicine (or its more ancient counterparts) has been forbidden?
        People know, almost instinctively, that if one person pays another to produce something, there is always, without fail, pressure to produce. As payments in the American health care system (to abuse the word) decline, and corporate ownership of physician practices climbs, does one think that there would _not_ be increased pressure to produce?
        What’s being “produced” by corporate entities, however, isn’t health, nor health care, nor wellness. It’s billings. And any physician who claims that there is no pressure to produce greater billings is either one of the (thankfully) decreasingly rare physicians who has dropped out of the third party payer system, or s/he is a liar.
        When third party payers provide money to third party billers on behalf of services provided by a “first party” physician to a “first party” patient, you can bet that neither of the third parties cares one iota about the ethics of the transaction – that’s a problem for the first parties. All the third parties care about is the web of distortion they can each spin in order to either increase or avoid the payments – because that’s their respective jobs, and business has no ethics other than maximizing profitability.
        With physicians facing job loss, and patients receiving what they perceive as free (or nearly free) care, the ethics of the situation break down pretty quickly. How can one possibly imagine any outcome other than the fraud the poster has described?
        As the pundits love to proclaim, the problem isn’t the players, it’s the game. And it’s been the game since Medicare was introduced in 1965.

        • Patient Kit

          It shouldn’t have to be a given that “business has no ethics other than maximizing profitability”. There is the radical concept of corporate responsibility to all stakeholders –to customers, to employees, to the community, not just to investors and top executives. I’m not saying that this happens much in the real world. But it could and should happen in all business, not just healthcare (if healthcare must be a business). It’s sad that we just accept that business equals no ethics and no corporate responsibility. It’s not essential to be unethical and exploitive to make a fair profit. We shouldn’t just accept this of banks, let alone hospitals.

      • http://www.barronbrown.net Barron Brown

        Administrative pressures vary. The ethical imperative does not. A provider’s signature constitutes a legal attestation. The signer should be prepared to read the note aloud, under oath, before a jury. Any provider not prepared to do so should think twice before signing.

        In providers’ defense, no one asked for an EHR to make fraud so easy. Temptation is never more than a mouse click away. The parent company has a duty not just to enforce correct behavior, but to actively support it with the right tools for the job. A skilled EHR team, coupled with strong and principled leadership, can create note templates and other tools that make it easy to do right, harder to do wrong. This is not so difficult or expensive as it sounds. Still, health care entities fail to dedicate resources to this effort. They have other priorities.

  • rbthe4th2

    I pointed out, after getting a copy of my records from a problem doc or two, that I noticed documentation differences. Docs weren’t happy, to put it mildly, as I requested records changes, as by the law I am entitled. No scribes. I would have asked the doctor about recording but I’m sure they would have said no. Asking deeper questions such as ‘what is the basis for X’ seems to be a problem also, as the doctors stated ‘I observed X’ but didn’t state WHY were also added to my records.
    The scribe hit it dead on the money, sad to say. Again, another reason why eventually patients will probably be able to record visits, if they want, as some of the obvious “inconsistencies” are going to start to stand out. When it gets to “the stand” in a law court, and then the doctor would have to explain how they stayed on time for visits but did X, Y, Z in 7 minutes with a full H&P is going to be very interesting.

    Especially when blood work tells another story.

    • drma

      I do not believe that doctors can legally make changes to your records, even at your request. It is my understanding that the medical record is considered a legal document and it is not supposed to be modified but it can be updated with additional comments. Going back and altering a previous report is usually seen as a sign of misconduct.
      It is also a problem that by intentionally incorrectly recording an encounter, the physician is creating a fraudulent document.
      However, if the case went to court, I suspect it would be the patient’s word against the doctor and the doctor will be the more likely to be believed unless the patient has some additional documentation to back up their side.

      • DoubtfulGuest

        What I’m familiar with is the records amendment request form. The patient fills it out and requests the amendment. I don’t think it involves deleting whatever was changed, just probably a strikethrough and all appropriate notations when adding the correct information. I wouldn’t know because I wasn’t successful. In my state at least, the doctor can accept or deny the request, and they get a lot of leeway in terms of their “discretion”. It’s really not that great for patients. They can just say the patient is evil or crazy or anything, really.

        Doctors are supposed to accept or deny the request in writing, IIRC there’s a blank on the form itself for that. Now, whether or not they follow the proper procedure is another matter entirely…

      • rbthe4th2

        That’s correct, you can ask for changes and yes, there are going to be questions because more and more we are seeing stories that show us the honesty of the medical profession, policing their own, just isn’t there. Not every judge and/or jury may be willing to accept someones’ word when their life is on the line compared to someone who truly has been injured. Yes I know there are greedy patients, but there are also risk managers and hospital lawyers that have deeper pockets than many people do.

  • http://cognovant.com/ W Joseph Ketcherside, MD

    i have always thought scribes are wrong for many reasons, and this just reinforces that belief.

    Courageous writer, thank you for your concern and honesty.

    hopefully when all the kids who can text in their sleep get through medical school they will laugh at the idea that someone needs to follow them around and get in the way between them, the patient, and their chart.

    • southerndoc1

      “hopefully when all the kids who can text in their sleep get through medical school”
      The same kids who think texting and driving is perfectly safe will have no compunction about texting while making life and death decisions.

  • NPPCP

    There is so much more to this than your point. ER physicians (and primary care employed physicians) are frequently treated like MULES to generate those extra dollars. The healthcare system is complex and it is that way FOR A REASON – to confuse and obfuscate. Insurance companies and hospital administrators and government entities have successfully burdened the actual people providing healthcare services with so many “to do lists” and “bullet points” that they are no longer able to function normally. Why in the world would a SALARIED physician ask a scribe to fudge on a patient note? What do they have invested in that? They will be paid no matter what. So WHERE is the pressure coming from? I respond to all of you here talking about “recording visits” and asking for your record to be corrected” and generally lambasting physicians for doing their best to please everyone involved. I can guarantee you if they completely pleased all of you, they would be out of a job and the next mule would be shipped in. The “scribe” did not tell the full story – how about the unmanageable volume of patients the physician is expected see? Why didn’t the “scribe” mention the impossibility of respectfully managing all of those patients? Is what happens wrong? Yes! Is it right to blast these physicians? No! Most of the responses here are typical of the lack of understanding of healthcare in our country and the desire for the “Me and My” mentality Americans have been bred with. Let me know YOUR profession and I will point out all of the things you do that daily that are “okay” in the interest of expedience. All of this comes from an NP who doesn’t believe we need to be “supervised” by physicians. Yet, I still understand their value and the blind spears that are thrown at them without knowing the full story.

    • DoubtfulGuest

      I’ve been sitting this one out til now because I’ve been feeling bad about my own situation in which a doctor misdiagnosed me, changed my records then blamed me and generally screwed me over. I haven’t had anything constructive to add. But some of the same things you say here went through my head, and I have empathy for your point of view. Do you have any thoughts in terms of solutions? I agree the whole big problem needs to be addressed, not just whatever side that’s convenient to act on, because it affects us personally. The only thing that’s been suggested to patients is to suck it up and move on, and that’s not acceptable.

    • Greg Stueve

      I am an employed family physician who knows the “full story” and sees patients using an EMR without committing fraud. You were saying…?

  • Wendy Felsenthal

    I would also suggest that the patient should be allowed to read what was written in chart and okay its content. Maybe after the scribe is done, I the patient am contacted to look it over and sign it stating that the info is correct . I think this would make everyone more accountable for what is said or written down.

    I have picked up my medical records, gotten copies etc. over the years and am SHOCKED at how much info is totally not correct , belongs to another patient, or some other transcribed misinformation, that, if were to be used as a basis for medical care in the future by a doctor or nurse reading these notes based on what was written down could kill me….Its really a HUGE point of contention w/ me.

    i have a friend who works in a specialist Dr.’s office and she tells me as well what you have written above.

    • rbthe4th2

      and trying to get them corrected, you would think someone was rewriting the Bible.

      • http://www.myheartsisters.org/ Carolyn Thomas

        One of my blog readers is a brain tumor survivor who told me an incredible story of her mission to get the word “anxiety” removed from her medical chart – a misdiagnosis first added by her primary care physician in 2005 despite her reports of throbbing pain behind her right eye and growing pressure headaches. He never reconsidered his “anxiety” misdiagnosis, which from that day forward remained at the top of her medical record. And it wasn’t just a comment – in her medical record, The Problem List is the first thing every subsequent doctor sees after her name and file number, and being an alphabetical list, “anxiety” was at the very top. She spent years trying to get that misdiagnosis removed from her chart. On June 8, 2012, she wrote me again to tell me that the word “anxiety” has been removed from her official Problem List, finally. She told me:

        “I am convinced that the word ‘anxiety’ has been an obstacle to my appropriate diagnosis and treatment.” More on this case at: http://myheartsisters.org/2012/06/04/anxious-female/

        • southerndoc1

          You’re talking about fundamentally changing the nature of the medical record.

          Physicians see it as a recording of their best impression of what is going on at that point in time, impressions that are inevitably going to change and be revised as more information becomes available. To me, removing a diagnosis that seemed to be the correct one at that time is a dangerous precedent to set and is really falsifying the record. If I thought the patient had pneumonia and it turned out after follow-up and testing that they had bronchitis, it would be unethical to go back and remove the first diagnosis.

          • http://www.myheartsisters.org/ Carolyn Thomas

            True, but in the case of an “anxiety” mislabel on an existing chart, many patients, particularly women, are pigeon-holed before the clinical examination even begins. Every symptom is thus interpreted through the lens of a misdiagnosis. Tragically common in women presenting with heart attack symptoms (eg NEJM reported that women experiencing MI are seven times more likely to be misdiagnosed and sent home from Emerg compared to our male counterparts – Pope et al, 2000). Misdiagnosis is a real and dangerous reality for patients, and being labelled an “anxious female” by mistake merely perpetuates that danger.

          • southerndoc1

            Sounds as if you’re almost saying that even if anxiety is a correct diagnosis it shouldn’t be listed in the chart?
            This is one of the problems arising when multiple doctors share a common medical record, and just about anyone can enter something into the problem list. There are many advantages to patients for keeping their health info in separate “silos” that they control.

          • http://www.myheartsisters.org/ Carolyn Thomas

            How do patients keep their health info “in separate silos that they control”?

          • southerndoc1

            Get your medical care from small private practices that aren’t owned by the big corporations. We don’t release your records, including your problem list, unless you request us to do so. No way a diagnosis of anxiety that I had made, correct or not, will be available to any ER doc.

          • rbthe4th2

            Not in Podunk, it doesn’t work that way.

          • DoubtfulGuest

            Some of us need care at teaching hospitals, though.

          • DoubtfulGuest

            Let me add that if I didn’t need such specialized care, I’d be glad to see doctors in small private practices. I’m in the process of starting my own business, nothing related to medicine. I want to work for myself, even though it might be a long process to make that happen. I’m supportive of physicians who don’t want to be employed/engulfed by CorpMed.

          • rbthe4th2

            The problem is that in my case, physical issues do corroborate my story and make the first “mental” claims wrong. Bronchitis to pneumonia is one thing, but its the mental to physical ones that cause the most damage.

          • DoubtfulGuest

            Anxiety. That old chestnut, one of my favorite topics. I appreciate your comments, southerndoc1. I just had a bad experience with this. I’d be just fine with a strikethrough on the anxiety diagnosis, so you can still see it. With the attached amendment “Turned out to be a brain tumor.”

            Anxiety is fear or apprehension out of proportion to the real threat, isn’t it? It’s the physician who didn’t pick up on the threat to this patient. Except the threat in her own mind, because we all know women’s minds are terrible things and need to be stopped?

            Medical stuff isn’t fun, and a certain amount of fear goes along with having a bad injury or disease.

            “A doctor’s best impressions” sounds lofty and infallible, but it’s not. I know of no other situation in which one human being is allowed to harm another with no apology because “that’s what I thought at the time”.

            At one point, after doctors wrote “anxiety” over and over in my charts, I thought: “If I’m so anxious and it’s distracting to my doctors, I should try extra hard to be calm and matter of fact. Maybe they’ll see it as a vote of confidence. Even though I’m feeling poorly, I trust them and I’m letting them do their thing.”

            So, I tried it. The very first time, that doctor decided I was malingering. Not anxious, but actually a bad person. I thought I was being polite and optimistic. He thought I was too smooth in my presentation, conniving, too comfortable in a medical setting. Because I failed to get the tone of the social interaction exactly right, while dealing with my progressive neurological disease alone and with no treatment.

            You’re each different in where your “line” is, that you think a patient is either anxious enough to make anxiety the primary diagnosis. Or OTOH, plotting, diabolical, and happy to be in your office for the wrong reasons.

            I believe in most cases, a misdiagnosis should be handled as a learning experience, along with a complete explanation and apology to the patient. Doctors might start with something like “Even after X years of being a doctor, I still have a lot to learn about reading people. What’s going on in my life that might make me easily exasperated with patients? Am I projecting any of my own anxiety onto others?”

          • http://www.myheartsisters.org/ Carolyn Thomas

            Absolutely correct, DoubtfulGuest. Here’s yet another tragic example: 37-year old woman
            misdiagnosed by three doctors with “anxiety” dies from metastatic lung
            cancer that her docs missed http://www.dailymail.co.uk/health/article-2290128/University-professor-37-dies-lung-cancer-doctors-dismissed-symptoms-anxiety-depression.html

          • southerndoc1

            Very sad story. The NHS GPs work on a nationally mandated 10 minutes/one problem per visit system. We’re rapidly headed in that direction, and I’m sure it will make misdiagnosis more common. If we want to reduce misdiagnosis, we have to make sure that docs have time to actually sit, listen, and think with their patients. I don’t see it happening.

          • DoubtfulGuest

            When docs become defensive and arrogant about their impressions, it helps keep the public from seeing how badly the time constraints affect the quality of their care. It just reinforces the status quo. I could never be mad at a physician who’d honestly say “I messed up badly, partly because I had ten minutes to do an hour’s worth of thinking, listening, and talking with my patient”.

            As hard as it may be to say that, it keeps you and your patients on the same side. When you say instead “That was my best assessment of you”, you’re kicking the patients when they’re already down.

          • http://www.myheartsisters.org/ Carolyn Thomas

            Southerndoc1, I hope you’re not saying that you believe for one nanosecond that such misdiagnosis is not already rampant in your country as well – or any other country in which physicians employ what Dr. Jerome Groopman calls “unwarranted clinical certainty.”

            Misdiagnosis already accounts for up to 80,000 hospital deaths per year in the U.S. – and that’s in a system that has little in common with the NHS. So you can appreciate how having that word “anxiety” mistakenly listed on any patient’s chart – especially AFTER the corrected Dx is finally reached – is a likely contributor to both misdiagnosis and missed diagnosis in the future. More at: http://myheartsisters.org/2012/01/08/unwarranted-certainty/

            As DoubtfulGuest correctly concludes: “A doctor’s ‘best impressions’ sounds lofty and infallible, but it’s not. I know of no other situation in which one human being is allowed to harm
            another with no apology because “that’s what I thought at the time”.

          • southerndoc1

            Read my comment before you start lecturing me. I said misdiagnosis will become “more common,” which means I accept that it is already common. But I don’t think the solution is shorter office visits and more clerical work for the doctor to complete during the visit. I guess you disagree.

            “Best impressions” is a commonly used phrase to indicate “the way I organized my thoughts at that point in time.” I don’t see that it’s anything to get so bent out of shape over.

          • DoubtfulGuest

            On anxiety and women’s minds:

            http://www.youtube.com/watch?v=LS37SNYjg8w

  • John

    You can simply ask for the scribe to leave the room. As a scribe, I was asked to leave a couple of times over 2 years and I excused myself on sensitive exams for females (I’m male). It’s not like we are actively trying to make you uncomfortable.

  • Deceased MD

    And you want to become a doctor after this?

  • NPPCP

    Just depends on the provider’s philosophy/load. You would be a hindrance to me in my privately owned practice. In the intimate setting of a primary care visit, a scribe is a third wheel, in my opinion. But, to each his own. They are yet another tool that some need to be able to keep up with the overwhelming requirements for documentation in the face of decreasing payor amounts.

    • Syl

      I agree with this. While scribes do work in primary care settings, I certainly wouldn’t say that scribes are for everyone. Some physicians don’t like the idea of scribes or don’t find them useful and that’s very much their own decision to make – 100% with you on that.

      My argument is merely that a medical scribe is a medical professional who has legitimacy and deserves respect.

  • Ronald Hirsch, MD

    This scribe should get the instruction to push the smoking counseling button on every smoker in writing and file a qui tam lawsuit. That is called fraud and is inexcusable.

    • NPPCP

      Against the HOSPITAL – for pushing the physician so hard to jack up the submitted billing….but FIRST, the scribe should quit instead of perpetuating this type of behavior. But, alas, it is wrong – but not “wrong enough” to lose their paycheck.

      • Ronald Hirsch, MD

        I would not be so fast to accuse the hospital; they are not always the bad guy. Many ED groups are independent entities, contracted with the hospital to provide services but not employed or controlled in any way with no input into their billing practices. This also applies to many hospitalist groups. The scribe may be employed by the hospital or the ED group. It may also just be a rogue physician that is flaunting the rules on their own.

  • JR

    Being a patient is so frequently a subject/object experience that adding another person in the room just makes the patient feel like even more of an object.

    That being said, having pulled my own paper records, I can vouch they had things in there the doctor didn’t do and were missing important pieces of information, as well as having someone else’s paperwork in my file. And that was for only 4 visits worth of records!

    • Suzi Q 38

      Welcome o the “club.”

      • rbthe4th2

        Yes and wait till you see the reaction when you do it!!

  • waitingtolisten

    The real problem in my mind is that I think physicians are pressured to be dishonest to make a living. What they do in their normal routine of doctoring isn’t enough to pay their paycheck. Perhaps if physicians were reimbursed better for their interactions they wouldn’t feel the need to be dishonest to make a living. I am a physician and I work in a system without scribes. I am my own scribe. And it sucks. I hate that I have to spend my whole damn day documenting rather than actually spending time with patients or making medical decisions or reviewing results. Yes, I spent 12 years in school and training to type on a computer all day. It’s infuriating.

  • southerndoc1

    Nothing is more indicative of the complete failure of EMRs on all accounts – cost savings, efficiency, accuracy – than the growth and success of scribe companies.

  • rbthe4th2

    Do you like staying on time for your appointments?
    If I can.
    Do you like going home late every day?
    I do anyway.
    Would you like the threat of “court, attorney” and other words hanging over your head every day?
    That’s part of being a doctor. You know that lawsuits are a part of professional life. Its the chance you take.
    I’d also disagree that everyone has the perspective you did. Some of us – like DG and I – didn’t until we suffered the effects of those who made mistakes and don’t want to work with us to fix the problems. Time and again it is mentioned that its more the attitude of the healthcare provider about whether someone wants to sue or not.
    Actually, I didn’t even ask or want the doctor to be involved. I just said file it in my records, here are my corrections. Whether or not they involve the doctor or not makes no difference to me. As long as my comments are in there, whether or not you stay late or not, doesn’t matter.
    Let me ask you something: when what you put in that record affects my health and the fellow doctors who treat me down the line depend on you to get it right (to save them in several ways), don’t you think providers should get it right? Do you have life threatening allergies? How about coming out of anesthesia in surgery? Hearing issues? What if those things weren’t written in the record and then YOU are the one making a mistake in diagnosing or delaying a diagnosis because a brother/sister healthcare provider didn’t or wouldn’t take the time to correct them?
    Its different when its your own child or you are the provider who got nailed because one of your own didn’t record correctly.
    I’m surprised that if you read mine and DG’s posts, you’d see time and again where we say we weren’t looking for lawsuits. I made that comment because I’m sure that at some point, the issues raised here are going to come up in a lawsuit somewhere. I would think that you know that once an HCP’s testimony is destroyed, like falsifying records, then the case is lost. So yeah, isn’t it important to get it right? Not just for the patient but for the provider?
    Do you think that when things like this happen, it is going to increase trust and respect for the profession?
    and yes, frankly a recording of a number of visits I’ve had with particular doctors would probably help both patients and the medical profession. I’ve got most every doctor know I don’t think I have to do that with. Sadly you have to admit that there are some HCP’s who would be better off being exposed so that those professionals who do dedicate themselves aren’t getting the whiff of the stench from the bad ones on them.
    This is where an ounce of prevention can sometimes work better than a pound of cure.
    What do you think will happen to the profession as a whole once the EHR is suspect in any little bit? Then even you all won’t be able to trust it and treat us. Do you think that’s going to help the profession?
    Randy

    • DoubtfulGuest

      I would actually be fine with never again ever mentioning legal stuff, if the health care professionals here feel that it would change the tone of our conversations enough to accomplish some real problem-solving together.

      I would like it if they would understand that we’re merely expressing frustration about bad things happening to us, and the system that gives us no constructive way to deal with it. I’ve made my feelings clear about the process-that-shall-not-be-named and the people who encourage it. And maybe what those people really need is to be steadfastly ignored while doctors and patients (and NPs, nurses, techs, and paramedics) concentrate on helping one another.

      • rbthe4th2

        Why? Its obviously on their mind more so than our well being, at least for some, that’s how they view us. Besides, the fact remains there ARE people that sue, and basically falsifying records is something that needs to be resolved before it does hit the fan.

        • DoubtfulGuest

          It sometimes feels like damned if we do, damned if we don’t bring it up because 1) if we do it sounds like a threat but 2) if we don’t, they figure it’s on our minds anyway, or it WILL be once we see a TV commercial for you-know-what. All this fear and suspicion whether or not the elephant in the room gets pointed out.

          I don’t have a TV. Yesterday, in my dentist’s office, they had theirs on and I was stunned to see not one but three, sleaze-tastic commercials for THAT in < 45 minutes.

          Yes, doctors bring it up quite a bit here even if we don't. They do put it ahead of our welfare and I hate that. I didn't say I had an awesome solution. Only that it's a good faith effort I'm willing to make if they think it would help anything.

  • http://cognovant.com/ W Joseph Ketcherside, MD

    Boy, isn’t that the truth!! If we think doctors complain now, wait until we get this young group comes in with their high expectations and recognition of how well-designed technology can help them. Based on their experiences with the rest of the world, I mean. But I consider that a much better problem to have. I hope that drives better user-focused design.

  • Disgruntled Nurse

    This scribe isn’t remotely alone in feeling pressure to commit fraud in electronic medical records. There are a lot of checkboxes in my charting which must be checked. Must. The chart cannot be completed unless they are checked, and so the standard practice is just to check them, no matter what.

    The documentation system we use is actually set up to require fraudulent charting. For some items, the only option is “Yes.” There will be two boxes, but the options are either “We did this thing.” or “This thing didn’t need to be done.” There is no option for “We did not do this thing, even though we should have.”

    When I was a newer nurse, I fought back a little. I refused to chart things that I didn’t do, or that other people didn’t do. And the hospital administration punished me for that. They quickly taught me that if I charted that something wasn’t done, that indicated only that I was being lazy or inefficient. Rather than admitting that there was a systemic problem and that we were being pressured to work too fast, I was accused of being a poor manager of my time. I would be told “Everyone else is able to get it done, so why can’t you.” The argument that everyone else is also lying in their charts is no defense, since I surely am not going to find a lot of my colleagues who would be willing to stand up with me to admit that.

    So, I have learned. Do what is really important for patient care, let the things that aren’t so important slide, but above all, chart that everything was done according to policy. Especially if it wasn’t.

    It is fraud, and I hate it. Should I quit my job so that I don’t have to do it? All that will do is lose me my livelihood. Since all my co-workers check the boxes without argument, I have evidence that I will simply be replaced by someone who isn’t so fussy about charting reality.

    I am looking for a job outside nursing entirely, and this the major reason. I am tired of lying.

    • rbthe4th2

      Bless you disgruntled. My other half makes goodies for the nurses during nurses’ week and at other times to say thank you. When I was in the hospital one time, she made sure I was taken care of, learned how to operate the IV pumps, etc. so that they wouldn’t have to do it. Even offered for one of them to give them some food because when asked, the nurse said she had a headache and hadn’t gotten a chance to eat.
      Randy

    • guest

      I entirely agree 100%

  • rbthe4th2

    Um what about nurses? Not all have masters and above, but they pretty much fit in the genre you’re looking at. I’d consider them professionals. Proud to know some too.

    • Ed

      I think my first paragraph clearly conveyed my thoughts. Certainly RNs and above meet “professional” criteria as well as LPNs to a degree (professional association and regulatory oversight). Short of physicians, patients have no reliable method to evaluate provider qualification and yet anyone who enters the hospital or physician exam room claims professional status.

  • guest

    Physicians are probably told they have to do smoking cessation counseling but they are not given the time to do this

    • rbthe4th2

      It could take the guise of ‘smoking is not healthy for you’, all of 5 seconds.

  • http://www.myheartsisters.org/ Carolyn Thomas

    I’ve never experienced having a scribe accompany any of my physicians during a consultation (never mind being “with them the entire shift, even during any breaks they take”). But I have had the experience of having my pain specialist dictate his follow-up notes to my GP into a dictaphone (remember those?) at the end of each regular visit, while I am still sitting there to hear what he’s saying about me and our visit. He told me once that he prefers to do this in front of the patient for two reasons: 1. the patient will hear the recap repeated of what was discussed during the visit, and 2. the patient will be able to interrupt to correct any details in case he had misinterpreted or forgotten to include something.

  • buzzkillerjsmith

    If you work for CorpMed, in any capacity at all, you put your soul at hazard.

    • rbthe4th2

      Which is why most doctors are, in one way or another, being led like sheep to the slaughter of ‘work for us, work for us: less on call or no call, 9-5, no billing or admin headaches’ …
      Like an advertisement from Satan.
      Now if you are a medical professional and you dislike my post, you must be retired.

  • http://www.capko.com Laurie Morgan

    I agree completely the penalties for bucking the system could be severe, especially when compared against the perceived cost of some of the requirements. (Of course it is a slippery slope. But doctors probably also ask, do patients benefit if I get fired for this seemingly minor breach and can’t care for them?)

  • ninguem

    The scribe is not the problem, as pointed out in other comments.

    Am I the only one that has a problem with the fact that things have become so complex that we require scribes in the first place?

    As I do all too often, compare with the places the “bien pensants” consider our “betters” in medicine. Pick your foreign country, UK, Germany, France, Australia, Israel. Do any of them use scribes for medical notes?

    Why should I need to hire another human being to document the care needed to treat a sore throat?

  • rbthe4th2

    The only time I’ve had one, they were simply introduced as the person taking notes. Nothing was said about informed consent or the like. Since I was dehydrated, I didn’t care but I still remember it more than a year ago. This is why there is so much of a problem – lack of informed consent, its called we don’t tell you anything and then phrase it in such a manner to make it so you DO consent.

  • rbthe4th2

    Exactly what happened in my case. I have some pretty great doctors now but I still have some nightmares from the old ones that still haunt my records.

  • Medical Board

    Don’t stand up to a physician who is committing fraud, not reporting errors that result in patient harm, or letting impaired residents provide patient care. You might be subsequently accused of having poor moral character by the medical board. After all, the physician can accuse you of wrongdoing and people will probably not believe a subordinate. Especially if the physician claims that instead of committing fraud, you simply were not paying attention. Add about 20 more false accusations of your performance once you question their unethical practice and then no one will believe you.

  • JR

    I love my doctors EMR. He lets me sees the notes he puts in it, and even discusses the notes with me as he enters them. He can pull up a graph of my test scores over time and show it to me as a visual aid. He prints out a letter at the end of each visit with our agreed upon treatment plan and a review of the visit.

    I understand some doctors are probably not that computer saavy, and that’s ok. But even those doctors don’t need scribes.

    My previous office (before I moved) had a “visit checksheet” type thing where they would record the visit. It was one page, and it would end up in my paper file. I didn’t like this because I was never allowed to see the notes, or my test results, it was all hidden from me as a patient. I hated the old “paper” processes as a patient.

    Yet, I see no reason a doctor can’t fill out a paper form, and hand it to the scribe to enter into the system, rather than have the scribe stay through out a visit.

    Look at studies about people and how they react one-on-one vs to a group – even how they react when they are on camera. The more people added in, the more the patient is going to reply based on what they think is socially acceptable rather than reply based on the truth. And the more stress the patient will be under if they do disclose the truth. It’s just bad for the patient all around, even if they don’t object because they are trying to be a “good patient”.

  • James J. Strafford

    I’ve followed the Scribe phenomenon closely and have written about it quite a bit. When it fist started booming 7-8 years ago industry colleages warned of the potential basically of enlisting a helper for fraud. Interstingly, up until this article, I’ve seen nothing negative about Scribes. Doesn’t mean it hasn’t happened. I did consulting for a large Oncology practice in the 90s that was in deep trouble with the Feds because their nurse-scribes who were empolyees of the practice ( a bad idea) were fabricating quite a bit of the chart documentation. All it takes is a disgruntled Scribe or coder to go Qui Tam and things could get very ugly.
    Probably the fact that Scribing has taken off and is being standardized with good training and a semblance of federal guidelines decreases the risk of the kind of trouble I saw in the 90s. Also as many have mentioned, documentation guidlines are basically a game that require a physician to document 2/3 of Family/Social/Previous Med History as well as 10 ROSs and 4 HPI elements for the coder to get to an ED 5 no matter how unrealistic that kind of work up might be for a given presenting problem in the ED. Essentaily the guidelines were written for office based docs who although over burrdened too have the time to document more fully.
    To the author, a reminder, it is completely legal and Kosher for a Scribe to take the Family/Social PMH and ROS. Hell the patient can complete their own ROS as long as the provider reviews and signs. Also there is a caveat for the many patients who report to EDs with life threatening emergencies, or the elderly with dementia. But the provider must dosument the issue which prevents a leisurly patient interview.
    But documenting “smoking cessation counseling” is fraud if the provider did not do that counseling. And the guidelines for that counseling are pretty specific and include follow up (not likely for an ED patient). Frankly I don’t see many EDs billing for that at this point because of the documentation requirements and the payors often don’t pay for it.

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