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Scribes Enhance Patient Care, Efficiency in ED Through Clinical Documentation

In October 2010, emergency physician Claire Plautz, MD, launched the RMH Emergency Department scribe program, in conjunction with JMU, to enhance patient care and improve physician efficiency.

Scribes are pre-med or allied health students from James Madison University as well as Eastern Mennonite University who observe and provide documentation for ED physicians as they provide patient care. At JMU, Dr. Plautz worked with Dr. Sharon Babcock, associate biology professor, associate director, Institute for Innovation in Health and Human Services, and director, Preprofessional Health Programs, to recruit students to the program.

The scribes accompany the physician as he or she provides patient care and performs clinical activities. The scribes document the physician-patient interaction, creating a thorough and accurate account of the patient's ED visit. The scribes' charts are clearly noted and verified before they become a permanent entry in the patient's medical record.

As part of the learning process, Dr. Plautz gives the scribes feedback on their notation, explains interesting physical exam or X-ray findings, and meets with them once a month to review the program. The scribes earn a modest stipend, but the true value of the program is the opportunity to be immersed in the clinical environment and to gain a realistic view of the medical profession. Scribes undergo extensive training, learning which historical elements are significant and studying aspects of the medical chart, medical terminology and coding. They also learn about patient confidentiality and professionalism.

Benefits for ED physicians and staff include increased timeliness of documentation, more accurate billing, and a positive impact on the patient-doctor interaction. Scribes help free physicians from the task of documentation, allowing them to focus more closely on the patient and maintain eye contact without having to look down or take notes. Recognizing the value of scribes, several other RMH ED physicians are also now using them.

Scribes commit to at least one semester, though many have stayed longer to gain more experience. The program has quickly become competitive, and Dr. Plautz is having to turn away outstanding applicants.

"Usually I hear glowing reviews from the students," says Dr. Plautz. "It's an outstanding addition to the student's medical school application packet. Admission committees tend to appreciate students who know what they're getting into before entering medical school." ED physician Claire Plautz, MD, collaborates with JMU student scribe Erin Albury. best and the brightest physicians and nurses who are interested in engaging in research. He says engagement in research helps improve the overall reputation as a community hospital.

"Research rounds support our innovation strategy and desire to be on the leading edge of new development that will help our patients," says Kay Harrison, RMH vice president, Business Development.

The research rounds allow JMU to groom the next generation of researchers and provide practical experience for other students. The rounds also offer a venue for those professors who must publish a certain number of papers each year to retain their positions. The rounds also offer a pipeline for innovation.

"The RMH/JMU research collaborative is one of the many fine examples of the work our two great organizations are doing together to build a stronger and more healthy community," says Dr. Marra. "Faculty members from the University and RMH medical staff physicians have been putting their collective efforts together to find solutions for health-related concerns and problems that face not only our community but the world as a whole. Some examples include collaboration to design heart imaging programs that generate data to better define proper treatment of various forms of heart failure and also research design engineering projects to create an artificial heart model that can generate data to predict prosthetic heart valve performance."

Dr Marra notes that it is not just the research mission that is served by the two institutions in these efforts, but also the very important education mission as well.

"Students from the undergraduate and graduate schools of JMU have worked very closely with our faculty and staff, and many have also elected to come and observe physicians working in both the operating suites and during clinical rounds," he says. "It has been both exciting and a wonderful experience to be a part of these two impressive institutions and I look forward to further strengthening this partnership."

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