Purpose of a Retina Scribe
Scribes are not diagnosticians — their role is to document findings and support the physician by keeping the EMR accurate, organized, and ready for next steps.
In retina practice, scribes must do more than transcribe words — they need to recognize terminology, anatomy, and workflows so they can anticipate and prepare the EMR efficiently.
Key Responsibilities
Accurately document physician findings in real time.
Anticipate orders and tests based on findings (without diagnosing).
Keep prior imaging and notes ready for comparison.
Understand retina-specific terminology.
Major Structures
Cornea – Clear front layer of the eye.
Lens – Focuses light on the retina.
Vitreous – Gel filling the eye’s center.
Retina – Light-sensitive layer at the back of the eye.
Macula – Central part of the retina for sharp central vision.
Fovea – Small pit inside macula, highest visual acuity.
Optic nerve/disc – Carries signals to the brain; known as the “blind spot.”
Blood Supply
Retina gets blood from the central retinal artery and vein.
Clinical Notes for Scribes
Doctors often mention macula, fovea, peripheral retina, optic disc in dictation.
Central vision = macula/fovea; Peripheral vision = outer retina.
Diabetic Retinopathy (DR)
NPDR (non-proliferative): Microaneurysms, hemorrhages, exudates.
PDR (proliferative): Abnormal new blood vessel growth (neovascularization).
DME (diabetic macular edema): Swelling at macula.
Age-Related Macular Degeneration (AMD)
Dry AMD: Presence of drusen (yellow deposits).
Wet AMD: Abnormal blood vessels leak fluid (subretinal fluid, hemorrhage).
Retinal Detachment
Symptoms: flashes, floaters, “curtain” vision loss.
Macular Hole & Epiretinal Membrane (ERM)
Hole in central retina (sharp vision loss).
ERM: Scar tissue on retina surface.
Retinal Vein/Artery Occlusion
Blocked vein → hemorrhages, swelling (macular edema).
Blocked artery → sudden, severe vision loss.
Terms to Recognize in Dictation
Drusen = AMD.
Exudates/hemorrhage = diabetes or vascular disease.
Neovascularization = abnormal vessels.
OCT (Optical Coherence Tomography)
Scan of retinal layers (especially macula).
Identifies macular edema, drusen, fluid, holes.
Fluorescein Angiography (FA)
Uses dye to evaluate retinal blood flow.
Detects leakage from abnormal blood vessels.
Fundus Photography
Photo of retina (often wide field).
Used for documentation and comparison.
Ultrasound B-scan
Used if retina can’t be seen due to blood or cataract.
Detects detachments, tumors, hemorrhage.
Practical Tip for Scribes
Always document results clearly.
Keep prior OCTs and photos open for comparison.
Intravitreal Injections
Most common: anti-VEGF drugs (Avastin, Lucentis, Eylea).
Used for wet AMD, diabetic macular edema, vein occlusion edema.
Anti-VEGF Mechanism
VEGF = vascular endothelial growth factor.
Anti-VEGF drugs stop abnormal blood vessel growth and leakage.
Laser Treatments
Used to seal retinal tears, treat leaking vessels, or reduce edema.
Vitrectomy Surgery
Removes vitreous gel.
Used for retinal detachments, macular holes, or vitreous hemorrhage.
Scribe Role
When hearing “injection,” “neovascularization,” “macular edema,” etc., prepare injection section in EMR.
Document treatment plan exactly as physician dictates.
Core Principles
Document findings verbatim from physician.
Use correct anatomic terms.
Pull up past imaging and compare with today’s results.
Anticipate likely orders (OCT, FA, injection).
Examples
If doctor says “macular edema,” be ready to add injection order.
If doctor says “drusen,” likely related to AMD monitoring.
If doctor says “flashes/floaters,” prepare retinal detachment workflow (OCT, ultrasound).
Key Workflow Differences in Retina
Heavy reliance on comparisons.
Frequent injections.
Many follow-ups to track disease over time.
Case Example 1: Diabetic Patient
Dictation: “Proliferative diabetic retinopathy with macular edema.”
Scribe actions: Document diagnosis, prepare injection order, ensure OCT loaded for comparison.
Case Example 2: AMD Patient
Dictation: “Drusen noted in macula, wet changes with subretinal fluid.”
Scribe actions: Document drusen, prepare injection section, note OCT findings.
Case Example 3: Retinal Detachment Suspicion
Dictation: “Patient reports curtain vision loss; retinal detachment suspected.”
Scribe actions: Document symptoms, prepare ultrasound B-scan order, note urgency.