1
Q
What is a scribe?
A
An unlicensed person performing documentation and other non-clinical tasks under the direction of a licensed independent practitioner.
2
Q
Scribes CAN…
A
- Document history, PE, results, procedures, and physician consults.
- Access and document laboratory results and radiology findings.
- Access and display X-rays for the physician to review.
- Locate and obtain PMHx and recent studies.
- Record physician interpretations of X-Rays and ECG’s.
3
Q
Scribes CANNOT…
A
- Touch patients.
- Write orders or prescriptions.
- Give verbal orders.
- Do anything that affects patients health.
- Sign or authenticate any chart or record.
- Handle bodily fluids or specimens.
4
Q
Subjective
A
Feeling
5
Q
Objective
A
Fact
6
Q
Chief Complaint
A
The main reason for the patient’s ED visit.
7
Q
Medical Decision Making
A
The physician’s thought process.
8
Q
Pain
A
Patient’s feeling.
9
Q
Tenderness
A
Physician’s assessment.
10
Q
Benign
A
Normal, nothing of concern.
11
Q
Distress
A
The doctor’s judgement of discomfort.
12
Q
Febrile
A
The state of having fever, concerning for infection.
13
Q
Acute
A
New onset, likely concerning.
14
Q
Chronic
A
Long-standing, not of direct concern
15
Q
Baseline
A
An individual’s normal state of being.
16
Q
Auscultation
A
Listening with a stethoscope.
17
Q
Palpation
A
The act of pressing on an area.
18
Q
Inpatient
A
Admitted to the hospital overnight.
19
Q
Outpatient
A
Seen and sent home the same day.
20
Q
People in ED
A
- Charge Nurse
- Mid-Level Provider (LPN or PA)
- ED Nurse
- Respiratory Therapist (RT)
- ED Tech
- Unit Secretary
- Scribe
21
Q
ED Flow
A
- Check in and Chief Complaint
- Physician Assessment
- Objective Orders and Results
- Medical Decision Making
- Disposition
22
Q
ED Flow: Before Orders
A
- Walk-In or EMS
- Triage
- Bed Placement
- History and Physical
- Physicians orders
23
Q
ED Flow: After Orders
A
- Differential Dx
- Physician orders
- Laboratory studies, imaging studies, procedures, medications.
- Results and ED course.
- Final Dx
- Disposition
24
Q
Triage
A
Chief Complaint
Vital Signs
Level of Acuity
25
Vital Signs
```
HR
BP
RR
T
SaO2
```
26
Nurse Assessment
1. Confirm chief complaint
2. Review allergies
3. Brief PMHx
27
History and Physical
1. Subjective (HPI & ROS)
2. Past History (PMHx, PSHx, FHx, SHx)
3. Objective (PE)
28
Differential Dx
A list of things that may be causing the pt's subjective symptoms.
29
Results and ED Course
Patient re-evaluations. Consults with specialists.
30
Disposition
1. Discharge Home
2. Admit for further care
3. Transfer to another facility
31
General Documentation Template
1. HPI (story and context of chief complaint)
2. ROS (positives and negatives)
3. Past History (PMHx, PSHx, SHx, FHx)
4. PE (physician's findings)
5. ED Course (Objective results)
6. Disposition ( discharge, admit, transfer)
32
High blood pressure
Hypertension (HTN)
33
High cholesterol
Hyperlipidemia (HLD)
34
Thyroid problem
Usually Hypothyroidism, sometimes Hyperthyroidism
35
Diabetes
Diabetes Mellitus (DM)
36
"I can only take pills for my diabetes"
Non-Insulin Dependent Diabetes Mellitus (NIDDM)
37
"I take shots (insulin) for my diabetes"
Insulin Dependent Diabetes Mellitus (IDDM)
38
Heart disease
Usually Coronary Artery Disease (CAD)
39
Heart attack
Myocardial Infarction (MI) and CAD
40
Heart failure
Congestive Heart Failure (CHF)
41
Irregular heartbeat
Atrial Fibrillation (A-Fib)
42
Murmur
Heart murmur
43
Episodes of abnormally fast/ racing heartbeat
Supraventricular Tachycardia (SVT)
44
Asthma
Asthma
45
Emphysema/ Chronic Bronchitis
Chronic Obstructive Pulmonary Disease (COPD)
46
Blood clot in lung
Pulmonary Embolism (PE)
47
Pneumonia
Pneumonia (PNA)
48
Reflux
Gastroesophageal Reflux Disease (GERD)
49
Ulcer
Gastric Ulcer or Peptic Ulcer Disease (PUD)
50
Pancreatitis
Pancreatitis
51
Hepatitis
Hepatitis A/B/C
52
Diverticulitis
Diverticulitis
53
Crohn's /UC
Crohn's Disease or Ulcerative Colitis
54
Irritable bowel
Irritable Bowel Syndrome (IBS)
55
Bladder infection
Urinary Tract Infection (UTI)
56
Kidney infection
Pyelonephritis (Pyelo)
57
Kidney stones
Renal calculi/ Nephrolithiasis
58
"I'm on dialysis"
Chronic Renal Failure (CRF) or End Stage Renal Disease (ESRD) on dialysis.
59
Enlarged prostate
Benign Prostate Hypertrophy (BPH)
60
Stroke
Cerebrovascular Accident (CVA)
61
Mini-stroke
Transient Ischemic Attack (TIA)
62
Seizures
Seizure disorder/Epilepsy
63
Brain bleed
Hemorrhagic CVA
64
Bipolar
Bipolar disorder
65
Schizophrenia
Schizophrenia
66
"I drink a lot"
ETOH abuse or Alcoholism
67
"I do drugs"
Substance Abuse
68
"Blood clot in my leg"
Lower Extremity Deep Vein Thrombosis (DVT)
69
"Bulge in my aorta" or "Triple A"
Abdominal Aortic Aneurysm (AAA)
70
"Bad blood flow to my legs"
Peripheral Vascular Disease (PVD)
71
"Numbness in my legs"
Peripheral Neuropathy
72
Low back pain
Chronic Low Back Pain
73
Bulging/Herniated disc
Degenerative Disc Disease (DDD)
74
Arthritis
Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA)
75
Joint pain (chronic)
Degenerative Joint Disease (DJD)
76
Weak/fragile bones
Often Osteoporosis
77
Cancer
Cancer or Carcinoma (CA): brain, breast, lung, colon, prostate, ovarian, skin, bone, leukemia or lymphoma.
78
Spread to my...
With metastases to the ...
79
Chemo
Chemotherapy
80
Radiation
Radiation therapy
81
They cut it out
Status-post surgical resection
82
It's gone
In remission
83
Tonsils removed
Tonsillectomy
84
Adenoids removed
Adenoidectomy
85
Ear tubes
Pressure Equalizer (P.E.) Tubes
86
Heart by pass
Coronary Artery Bypass Graft (CABG) --> PMHx CAD
87
Stents
Coronary Stents --> PMHx CAD
88
Heart Cath
Cardiac catheterization
89
Balloon
Angioplasty --> PMHx CAD
90
Valve surgery
Valve repair or replacement (Bovine vs. Mechanical)
91
Pacer
Pacemaker
92
Defibrillator
Automatic Implanted Cardiac Defibrillator (AICD)
93
Surgery for Afib
Afib s/p cardiac ablation
94
Breast removal
Mastectomy
95
Hole in my neck
Tracheostomy (commonly called "trach")
96
Part of my lung removed
Partial lobectomy
97
Appendix removed
Appendectomy
98
Gallbladder removed
Cholecystectomy
99
Hernia repair
Herniorrhaphy
100
Part of my colon removed
Partial colectomy
101
Bag to collect stool
Colostomy
102
Spleen removed
Splenectomy
103
Stomach stapled
Gastric bypass
104
Exploratory
Exploratory Laproscopy (ExLap)
105
Kidney removed
Nephrectomy
106
Uterus removed
Hysterectomy (partial vs. total)
107
Ovary removed
Oophorectomy
108
Ovary and Fallopian tubes removed
Salpingo-oophorectomy
109
Tubes tied
Tubal ligation (female) or Vasectomy (male)
110
C-Section
Cesarean Section
111
Prostate removed
Prostatectomy (most often Trans-Urethral Removal of the Prostate, or TURP)
112
Uterine product removed
Dilation and Curettage (D&C)
113
Neck artery cleaned
Carotid Endarterectomy
114
Brain surgery
Craniotomy (brain bleed vs. brain CA)
115
Shunt
Ventriculoperitoneal (VP) Shunt
116
Dialysis fistula
AV (arteriovenous) Fistula
117
Dialysis graft
AV Graft
118
PICC Line
Peripherally Inserted Central Catheter (PICC)
119
Port
Port-a-cath or Medi-Port
120
Clot filter (lower abdomen)
IVC (inferior vena cava) Filter
121
Clot filter (leg)
Greenfield Filter
122
Leg amputated
Above Knee Amputation (AKA)
| Below Knee Amputation (BKA)
123
Joint repair
Arthroplasty
124
Metal plates/pins
Hardware
125
Neck fused
Cervical spinal fusion
126
Back fused
Lumbar spinal fusion
127
Hip surgery
Open Reduction with Internal Fixation (ORIF)
128
True Allergy
Rash
Itching
Swelling
Difficulty breathing
129
Family History
```
General
Cardiac
Pulmonary
Gastrointestinal
Neurological
Miscellaneous
```
130
Social History
```
Tobacco Use
Alcohol Use
Illicit Drug Use
Occupation
Living Circumstances
```
