📘 Retina Scribe Training Course

Introduction to Retina Scribing

Scribes are not diagnosticians — their role is to document physician findings and keep the EMR accurate, organized, and ready for next steps.

In retina practice, scribes must do more than transcribe. They need to recognize terminology, anatomy, and workflows so they can anticipate physician needs and prepare the EMR efficiently.

Key Responsibilities

  • Document physician findings in real time.

  • Anticipate orders/tests based on findings (without diagnosing).

  • Keep prior imaging available for comparison.

  • Understand retina-specific terminology.

Anatomy of the Eye (Focus on Retina)

Major Structures

  • Cornea – Clear front layer, helps focus light.

  • Lens – Focuses light onto the retina.

  • Vitreous – Gel filling the center of the eye.

  • Retina – Light-sensitive layer at the back of the eye.

  • Macula – Central retina; sharp central vision.

  • Fovea – Small pit inside macula; highest visual acuity.

  • Peripheral Retina – Side vision, motion detection.

  • Optic Disc/Nerve – Entry/exit of optic nerve; “blind spot.”

  • Blood Supply – Central retinal artery & vein.

Scribe Tip: When doctors mention macula or fovea, they’re referring to central vision. When they say peripheral, it’s outer retina.

Common Retina Diseases & Key Terms

Diabetic Retinopathy (DR)

  • NPDR (Non-Proliferative): Microaneurysms, hemorrhages, cotton wool spots, exudates.

  • PDR (Proliferative): Abnormal new blood vessel growth (neovascularization).

  • DME (Diabetic Macular Edema): Swelling in macula → vision loss.

Age-Related Macular Degeneration (AMD)

  • Dry AMD: Drusen (yellow deposits under retina).

  • Wet AMD: Abnormal vessels leak blood/fluid (subretinal fluid, hemorrhage).

Retinal Detachment

  • Symptoms: Flashes, floaters, curtain-like vision loss.

  • Urgent condition — may require surgery.

Macular Hole & Epiretinal Membrane (ERM)

  • Macular Hole: Hole in central retina → sharp vision loss.

  • ERM: Scar tissue on surface of retina, can distort vision.

Retinal Vein/Artery Occlusions

  • Vein Blockage: Hemorrhages, swelling (macular edema).

  • Artery Blockage: Sudden, severe, painless vision loss.

Scribe Tip:

  • Drusen → AMD

  • Exudates/hemorrhage → Diabetes/vascular

  • Neovascularization → New abnormal blood vessels

Retina Imaging and Diagnostics

  • OCT (Optical Coherence Tomography):
    Cross-sectional scan of retina; detects edema, drusen, fluid, holes.

  • FA (Fluorescein Angiography):
    Dye highlights blood vessels; detects leakage, neovascularization.

  • Fundus Photography:
    Wide-field retina photos for documentation and comparison.

  • Ultrasound B-Scan:
    Used if retina can’t be seen (blood, cataract). Detects detachments, tumors, hemorrhage.

Scribe Tip: Always have prior OCTs and fundus photos open for comparison.

Retina Treatments

  • Anti-VEGF Injections

    • Drugs: Avastin, Lucentis, Eylea.

    • Used for wet AMD, DME, vein occlusion edema.
      Block VEGF = stops abnormal vessel growth & leakage.

  • Laser Therapy

    • Seals tears, treats leaky vessels, reduces edema.

  • Vitrectomy Surgery

    • Removes vitreous gel.

    • Used for detachments, macular holes, vitreous hemorrhage.

Scribe Tip:

  • If doctor says “macular edema” or “neovascularization” → Prep injection section.

  • If “retinal tear” → Prep laser treatment section.

  • If “flashes/floaters” → Prep ultrasound B-scan workflow.

EMR Workflow & Scribe Role in Retina

  • Document verbatim what physician says.

  • Use correct anatomical terms.

  • Have imaging ready (OCT, FA, Fundus).

  • Anticipate likely orders based on findings.

  • Recognize patterns (frequent injections, follow-ups, comparisons).

Examples:

  • “Macular edema” → injection workflow.

  • “Drusen” → AMD monitoring.

  • “Curtain vision loss” → possible retinal detachment, prep ultrasound.

Putting It All Together: Case Studies

Case 1: Diabetic Patient
Dictation: “Proliferative diabetic retinopathy with macular edema.”

  • Scribe: Document diagnosis, prep injection order, open OCT.

Case 2: AMD Patient
Dictation: “Drusen noted with subretinal fluid.”

  • Scribe: Document drusen, prep injection section, compare OCT.

Case 3: Retinal Detachment Suspicion
Dictation: “Patient reports curtain vision loss.”

  • Scribe: Document symptoms, prep ultrasound B-scan, mark urgency.