This will bring you to the Scribe home where you can begin your case list. The number of total, complete and incomplete cases will always appear first with a list of incomplete cases underneath.
Entering a New Case
Clicking the Add Case tab will go to a blank case list form where a new case is created and added.
Enter patient information in all fields; if all fields are not complete the case will show up in the incomplete case until all fields are complete.
Enter Patient Initials: Do not enter in full name of patient
Enter Patient ID: Use the same patient ID as the hospital’s medical record ID for all procedures. This allows the Medical Records Director to cross-reference the cases you input into Scribe with his/her records at the hospital for verification. Do not use full social security numbers to protect patient confidentiality.
Enter Patient's Age: Patient's age at time of procedure in years.
Select Patient Gender.
Enter Date of Surgery/Treatment: Multiple procedures on the same patient and on the same date should be entered as one case.
Enter Diagnosis (ICD-9 or ICD-10) Code: Only one code is required.
Enter Treatment (CPT) Code: Only one code is required.
Enter date of last Follow up: The last time the patient was seen.
Enter Description of Operation: In 100 characters or less, list the procedures performed in the surgery.
Indicate if there were unexpected re-operation within 90 days. If yes, a box will ope where you need to explain it.
Indicate if there were unexpected re-admission within 90 days. If yes, a box will ope where you need to explain it.
Indicate if there were any anesthetic complications. If yes, check the box next to the type(s) of complications(s). Then, use the pulldown menu next to the choice to classify the severity. Finally, explain the complication.
Indicate if there were any surgical/technical complications. If yes, check the box next to the type(s) of complications(s). Then, use the pulldown menu next to the choice to classify the severity. Finally, explain the complication.
Indicate if there were any medical complications. If yes, check the box next to the type(s) of complications(s). Then, use the pulldown menu next to the choice to classify the severity. Finally, explain the complication.
Reset: Clear all fields with data entered and start all over Delete Case: Removes this case from the list Save Case: Case will be listed in incomplete case list and missing information can be entered at a later time Complete Case: All information is entered for this case
Incomplete cases always appear on the Scribe home page. Cases can be completed by clicking on the Scribe Case # of the particular case. All cases must be complete before list can be finalized.
Editing a Completed Case by Hospital
Click the Edit Case tab.
Select the hospital at which the case was performed.
A list of all cases for that hospital will be displayed
Case list can be ordered by Scribe Case #, Patient ID or Date of Surgery, just click the corresponding header at the top of the case list
Click on a Scribe Case # to go into a case and edit it
A case to be edited can also be found by searching as described below
Searching For a Case
On any page in the Scribe case list, cases can be searched by Patient ID, Hospital Name, and Surgery Date A list of all cases matching the search criteria entered will be displayed These cases can be viewed and/or edited by clicking the Scribe Case #
Print Case Lists
Print a case list for each hospital and review entered information prior to finalization. Statistics on all cases with complication reported will appear at the bottom of each case list.
Select the Print Cases tab.
Click Print Case List
Click the hospital whose case list you want printed.
Case lists will open in Adobe Acrobat Reader which you need installed on your computer in order to view the case list.
Once all information has been entered and verified to be correct, the case list can be finalized. Case lists with incomplete cases cannot be finalized. After finalization the case list is locked and no changes can be made. If an error is found after finalization, please call the ABOS.
Click the Finalize List tab and then click on Finalize list to finalize
Click the help tab to enter a trouble ticket or contact technical support.