📘 Retina Scribe Training Course

Introduction to Retina Scribing

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.

Anatomy of the Eye (Focus on Retina)

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.

Common Retina Diseases & Terms

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.

Retina Tests and Imaging

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.

Retina Treatments

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.

EMR Workflow for Retina

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.

Putting It All Together

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.