1
Q
Subjective vs. Objective
A
Subjective: feeling (what patient says)
Objective: fact (observations by medical team)
2
Q
Chief Complaint
A
The main reason for the patient’s ED visit
3
Q
Medical Decision Making
A
(MDM)
-the physician’s thought process
4
Q
Pain vs. Tenderness
A
Pain=patient’s feeling (subjective)
Tenderness=physician’s assessment (objective)
5
Q
Benign
A
Nothing of concern
6
Q
Distress
A
The doctor’s judgement of discomfort
7
Q
Febrile
A
The state of having a fever, concerning for infection
Temp greater than 100.4
8
Q
Acute
A
New onset, likely concerning
-duration less than 3 months
9
Q
Chronic
A
Long-standing, not of direct concern
-duration greater than 3 months
10
Q
Baseline
A
An individual’s normal state of being
11
Q
Auscultation
A
Listening with a stethoscope
12
Q
Palpation
A
Act of pressing an area (by the doctor)
13
Q
Inpatient
A
Admitted to the hospital overnight
14
Q
Outpatient
A
Seen and sent home the same day
15
Q
What is a scribe?
A
Unlicensed person performing documentation and other non-clinical tasks under direction of licensed independent practitioner
16
Q
Scribes CAN…
A
- document Hx, PE, results, procedures and physician consults
- access and document lab results and radiology findings
- access and display X-rays for physician review
- locate and obtain PMHx, previous charts, past results, and recent studies
- record physician interpretations of X-rays and ECGs
17
Q
Scribes CANNOT…
A
- touch patients
- write orders or prescriptions
- give verbal orders
- partake in any activity that may affect patient health or outcome
- sign or authenticate any chart or record
- handle bodily fluids or specimens
18
Q
People in the ED
A
- Mid-Level Provider—> NP or PA that works under the supervision of physician to diagnose and treat patients
- Charge Nurse—> manages the ED patient flow
- ED Nurse—> records medical hx, sx, monitors the patient, starts IVs, administers meds, and assists with procedures
- ED Tech —> helps the Nurse and assists with procedures
- Respiratory Therapist (RT)—>administers breathing treatments and assists with managing a patient’s airway
- HUQ/Unit Secretary —> answers phone calls, pages other specialists/doctors, and organizes the patient’s paperwork
- Scribe—> documents the patient’s visit on behalf of the physician
19
Q
Emergency Department Flow: Overview
A
Check In and Chief Complaint—> Physician Assessment —> Objective Order and Results—> Medical Decision Making —> Disposition
20
Q
Triage
A
- chief complaint
- vital signs
- level of acuity —> 5 (low) to 1 (high)
21
Q
Vital Signs
A
- HR=Heart rate—> 60-100bpm
- BP=Blood Pressure—> 90/60-120/80 mm/Hg
- RR=Respiratory Rate—> 12-20
- Temperature—> 98.6
- SaO2=oxygen saturation—> above 96%
22
Q
Nurse Assessment
A
- confirm chief complaint
- review allergies
- brief past history
23
Q
Differential Diagnosis
A
Based on the H&P the physician generates a list of things that may be causing the patient’s subjective symptoms.
-Then the doctor places orders to “rule out” each differential
24
Q
Final Dx
A
By using medical decision making the physician reviews specific results that can rule out differential diagnosis to reach the final diagnosis
25
History of Present Illness (HPI)
The story and context of the chief complaint
| [subjective]
26
Review of Systems (ROS)
A head-to-toe list of positives and negatives
| [subjective complaints]
27
Past History
- Past Medical History (PMHx)
- Past Surgical History (PSHx)
- Social History (SHx)
- Family History (FHx)
28
Physical Exam (PE)
The physicians objective findings
| [objective evaluation]
29
ED Course
```
Objective results (labs, imaging, re-evals, consults, procedures)
[objective evaluation]
```
30
Disposition
- Discharge Home
- Admit for further care
- Transfer to another facility
31
High Blood Pressure
[General]
| Hypertension (HTN)
32
High Cholesterol
[General]
| Hyperlipidemia (HLD)
33
Thyroid Problem
[General]
| Usually hypothyroidism, sometimes hyperthyroidism
34
Diabetes
```
[General]
Diabetes Mellitus (DM)
```
35
“I only take pills for my diabetes”
[General]
| Non-Insulin Dependent Diabetes Mellitus (NIDDM)
36
“I take shots (insulin) for my diabetes”
[General]
| Insulin Dependent Diabetes Mellitus (IDDM)
37
Heart Disease
[Cardio]
| Usually coronary artery disease (CAD)
38
Heart Attack
```
[Cardio]
Myocardial Infarction (MI)
```
39
Heart Failure
[Cardio]
| Congestive Heart Failure (CHF)
40
Irregular Heartbeat
[Cardio]
| Arrhythmia, Atrial Fibrillation
41
Murmur
[Cardio]
| Heart murmur
42
Episodes of abnormally fast/racing heartbeat
[Cardio]
| Arrhythmia, supraventricular tachycardia (SVT)
43
Asthma
[Pulmonary]
| Asthma
44
Emphysema/Chronic Bronchitis
[Pulmonary]
| Chronic Obstructive Pulmonary Disease (COPD)
45
Blood Clot in Lung
```
[Pulmonary]
Pulmonary Embolism (PE)
```
46
Pneumonia
[Pulmonary]
| Pneumonia (PNA)
47
Reflux
[GI]
| Gastroesophageal Reflux Disease (GERD)
48
Ulcer
[GI]
| Gastric Ulcer or Peptic Ulcer Disease
49
Pancreatitis
[GI]
| Pancreatitis
50
Hepatitis
[GI]
| Hepatitis
51
Diverticulitis
[GI]
| Diverticulitis
52
Crohn’s/UC
[GI]
| Crohn’s Disease or Ulcerative Colitis
53
Irritable Bowel
[GI]
| Irritable Bowel Syndrome (IBS)
54
Bladder Infection
[GU]
| Urinary Tract Infection (UTI)
55
Kidney Infection
[GU]
| Pyelonephritis (Pyelo)
56
Kidney Stones
```
[GU]
Renal Calculi (Nephrolithiases)
```
57
“I’m on dialysis”
[GU]
Chronic Renal Failure (CRF)
or
End Stage Renal Disease (ESRD) on dialysis
58
G/P/A
Gravida/Para/Abortion
Gravida= total number of times the patient has been pregnant
Para= the number of pregnancies reaching a viable gestational age (23 weeks)
Abortus= the total number of miscarriages or elective abortions
59
Brain Bleed
[Neuro]
| Hemorrhagic Cerebrovascular Accident (CVA)
60
Stroke
[Neuro]
| Ischemic Cerebrovascular Accident (CVA)
61
Mini-Stroke
[Neuro]
| Transient Ischemic Attack (TIA)
62
Seizures
[Neuro]
| History of seizures
63
Bipolar
[Psych]
| Bipolar Disorder
64
Schizophrenia
[Psych]
| Schizophrenia
65
“I drink a lot”
[Psych]
| EtOH Abuse or Alcoholism
66
“I do drugs”
[Psych]
| Substance Abuse
67
“Blood clot in my leg”
[Vascular]
| Lower extremity deep vein thrombosis (DVT)
68
“Bulge in my aorta”
[Vascular]
| Aortic Aneurysm
69
“Bad blood flow to my legs”
[Vascular]
| Peripheral Vascular Disease (PVD)
70
“Numbness in my legs”
[Vascular]
| Peripheral Neuropathy
71
Low Back Pain
[Musculoskeletal]
| Chronic low back pain
72
Bulging/Herniated Disc
[Musculoskeletal]
| Degenerative Disc Disease (DDD)
73
Arthritis
[Musculoskeletal]
Usually Osteoarthritis (OA)
Sometimes Rheumatoid Arthritis (RA)
74
Weak/Fragile Bones
[Musculoskeletal]
| often osteoporosis
75
Cancer
[Cancer]
Cancer or carcinoma (CA)
*Brain, breast, lung, colon, prostate, ovarian, skin, bone, leukemia, lymphoma
76
Spread tp my...
[Cancer]
| With metastasis to the...
77
Chemo
[Cancer]
| Chemotherapy
78
Radiation
[Cancer]
| Radiation Therapy
79
They cut it out
[Cancer]
| Status-post surgical resection
80
It’s gone
[Cancer]
| In remission
81
-ectomy
Surgical removal
82
Tonsils Removed
[ENT PSHX]
| Tonsillectomy
83
Adenoids removed
[ENT PSHX]
| Adenoidectomy
84
Ear Tubes
[ENT PSHX]
| Myringotomy or Pressure Equalizing (P.E.) Tubes
85
Heart Cath
[Cardiovascular PSHX]
| Cardiac Catheterization
86
Balloon
[Cardiovascular PSHX]
Angioplasty
* PMHx CAD
87
Stents
[Cardiovascular PSHX]
Coronary Stents
*PMHx CAD
88
Heart Bypass
[Cardiovascular PSHX]
Coronary Artery Bypass Graft (CABG)
*PMHx CAD
89
Valve Surgery
[Cardiovascular PSHX]
Valve-repair or replacement
(Bovine vs. Mechanical)
90
Pacer
[Cardiovascular PSHX]
| Pacemaker
91
Defibrillator
[Cardiovascular PSHX]
| Automatic Implanted Cardiac Defibrillator (AICD)
92
Surgery for Afib
[Cardiovascular PSHX]
| Afib s/p cardiac ablation
93
Breast Removal
[Pulm/Chest PSHX]
| Mastectomy
94
Hole in my neck
[Pulm/Chest PSHX]
| Tracheostomy (commonly called a trach)
95
Part of my lung removed
[Pulm/Chest PSHX]
| Partial lobectomy
96
Appendix Removed
[GI PSHX]
| Appendectomy
97
Gallbladder Removed
[GI PSHX]
| Cholecystectomy
98
Hernia Repair
[GI PSHX]
| Herniorrhaphy
99
Part of my colon removed
[GI PSHX]
| Partial colectomy
100
Bag to collect stool
[GI PSHX]
| Colostomy
101
Spleen removed
[GI PSHX]
| Splenectomy
102
Spleen removed
[GI PSHX]
| Splenectomy
103
Stomach Stapled
[GI PSHX]
Bariatric surgery
(Gastric sleeve, gastric bands/lap band, gastric bypass, etc)
104
Exploratory
```
[GI PSHX]
Exploratory Laparaoscopy (ExLap)
```
105
Kidney Removed
[GU PSHX]
| Nephrectomy
106
Uterus Removed
[GU PSHX]
| Hysterectomy (partial vs. total)
107
Ovary Removed
[GU PSHX]
| Oophorectomy
108
Ovary and Fallopian Tubes Removed
[GU PSHX]
| Salpingo-oophorectomy
109
Tubes Tied
[GU PSHX]
Tubal Ligation (female)
Vasectomy (male)
110
C-Section
[GU PSHX]
| Cesarean Section
111
Prostate Removed
[GU PSHX]
Prostatectomy or Prostate Resection
*most often transurethral resection of the prostate TURP
112
Uterine Product Removed
[GU PSHX]
| Dilation & Curettage (D&C)
113
Neck artery cleaned
[Neuro PSHX]
| Carotid endarterectomy
114
Shunt
[Neuro PSHX]
| Cerebral shunt
115
Brain Surgery
[Neuro PSHX]
| Craniotomy (brain bleed vs. brain CA)
116
Dialysis Fistula
[Vascular PSHX]
| Arteriovenous (AV) Fistula
117
Dialysis Graft
[Vascular PSHX]
| Arteriovenous (AV) Graft
118
PICC Line
[Vascular PSHX]
| Peripherally Inserted Central Catheter (PICC)
119
Port
[Vascular PSHX]
| Port-a-Cate or Medi-Port
120
Clot Filter (Lower Abdomen)
[Vascular PSHX]
| IVC (Inferior vena cava) Filter
121
Leg Amputated
[Ortho PSHX]
Above Knee Amputation (AKA)
Below Knee Amputation (BKA)
122
Joint Repair
[Ortho PSHX]
| Arthroplasty
123
Metal Plates/Pins
[Ortho PSHX]
| Hardware
124
Neck/Back Fused
[Ortho PSHX]
| Cervical/Lumbar Spinal Fusion
125
New Hip
[Ortho PSHX]
| Total hip replacement/Open Reduction with Internal Fixation (ORIF)
126
Genetic Risk vs. Environmental Risk
[FMHx]
- age of onset of dz important
- younger age old onset means higher genetic risk
- older age of onset (55 y/o+) is likely more use to environment than genetics
- genetic risk for the disease is higher if multiple blood-family members suffer from the same disease
127
Family History (FHx)
- General—> HTN, DM, CA
- Cardiac—> MI/CAD less than 55 y/o [genetic]
- Pulmonary—> PE, Asthma
- Gastrointestinal—> Crohn’s, IBS
- Neurological—> CVA, Aneurysm, Seizures
- Misc.—> Sickle Cell Anemia, DVT
128
Social History (SHx)
- Tobacco Use
- Alcohol Use (EtOH)
- Illicit Drug Use
- Occupation
- Living Circumstances
129
Tobacco Use (SHx)
- Smoking status
* current (#ppd, #yrs)
* Former (year quit)
* Never
* Second-hand exposure (pediatrics)
* E-cigs (Nicotine use)
- Chewing tobacco
130
Alcohol Use (SHx)
- Never
- Occasionally/socially
- Daily
- Chronic alcoholic
* number of drinks/day
* type of alcohol (beer/wine/liquor)
One drink equals:
- 12oz beer (5% alc)
- 8-9 oz of malt liquor (7% alc)
- 5oz of wine (12% alc)
- 1.5oz shot (40% alc, 80-proof)
131
Illicit Drug Use (SHx)
- Which drug
* heroin
* cocaine
* methamphetamine
* marijuana
* narcotics
- Route of administration
* Oral
* Inhaled
* Injected
- Date of last use
132
Occupation (SHx)
- Employed
- Unemployed
- On disability
- Retired
*if a physician asks specifically about type of work, be sure to document it
133
Living Circumstances (SHx)
- Lives alone
- With family/friends
- Nursing home/assisted living
- Hospice
- Homeless/shelter
134
Pediatrics (SHx)
- caretaker (mother, father, etc.)
- attends daycare
- attends school
- has brothers/sisters
- second hand smoke exposure
- immunizations up to date
135
What are the 4 types of Hxs?
1) PMHx
2) PSHx
3) FHx
4) SHx
136
The HPI and ROS are what type of info, subjective or objective?
Subjective
137
The Physical Exam is what type of info, subjective or objective?
Objective
138
While evaluating a patient complaining of CP your physician tells you heart sounds are normal, would you document this in HPI, ROS or PE?
PE
139
Would you be contradicting yourself if you wrote “the patient has abdominal Pain” in HPI but then later wrote in PE “the abd is nontender”?
No
- Pain=subjective and patient reported
- Tenderness=objective assessment of pain
140
What does disposition mean?
Patient’s destination after they leave the ED
141
What subcategories are included in the Past Hx section of the template?
PMHx—> HTN, DM, CAD, MI
PSHx—> appendectomy, cholecystectomy, CABG
FHx—> Hx of CAD <55yo
SHx—> EtOH, smoking, drug abuse, occupation
142
Abbreviation Heart Attack
MI—> Myocardial Infarction
143
Abbreviation Hypertension
HTN
144
Medical Term for Acid Reflex
GERD—> Gastroesophageal Reflux Disease
145
Medical Term for Stroke
Cerebrovascular Accident—>CVA
146
Term for Gallbladder Removal
Cholecystectomy
147
NKDA
No Known Drug Allergies
148
Medical term for Redness
Erythema
149
Medical Term for Bruising
Ecchymosis
