Charting Components

Question 1

what does the emergency department treat

Answer 1

emergent, urgent, and non-urgent conditions

Question 2

what does urgent care treat

Answer 2

urgent and non-urgent conditions

Question 3

what do outpatient clinics treat

Answer 3

family medicine/internal medicine or specialty medicine

Question 4

what is the chief complaint (CC)

Answer 4

the reason the patient is coming in to be seen by the provider

Question 5

what are the types of chief complaints in the emergency department

Answer 5

an acute complaint

Question 6

what are the types of chief complaints in the outpatient clinic

Answer 6

an acute complaint, new patient, follow up visit

Question 7

what does HPI stand for

Answer 7

history of present illness

Question 8

what is the HPI for

Answer 8

to expand and further describe the chief complaint. subjective information

Question 9

what does ROS stand for

Answer 9

review of symptoms

Question 10

what is the ROS for

Answer 10

this section of the note is a list of body systems with common symptoms for each body system. subjective information

Question 11

what does a typical review of systems include

Answer 11

constitutional, eyes, ENT, heme/lymph, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, neurological, integumentary, allergy/immunology, endocrine, psychiatric

Question 12

what is the past medical, social, and family history section for

Answer 12

where we find the patients medical history, surgical history, family history and social history

Question 13

what does the past medical history include

Answer 13

long term, diagnosed, medical conditions the patient has

Question 14

what does the past family history include

Answer 14

long term diagnosed medical conditions for a patients immediate family members

Question 15

what does the past social history include

Answer 15

social habits affecting the patients medical history , commonly asked about tobacco and alcohol and drug use

Question 16

what does the physical exam explain

Answer 16

it is a list of body systems where we document what the medical provider finds when examining the patient. objective findings

Question 17

what is the impression assessment diagnosis

Answer 17

the section of the note where we record the diagnoses which is a cause of the patients symptoms

Question 18

what would a normal physical exam for the general section look like

Answer 18

alert. no acute distress. non-toxic appearing

Question 19

what would a normal physical exam for the head/neck section look like

Answer 19

normocephalic, atraumatic, neck supple

Question 20

what would a normal physical exam for the eyes section look like

Answer 20

pupils are equal, round, and reactive too light. extra ocular movements intact

Question 21

what would a normal physical exam for the ENT section look like

Answer 21

external ears are normal

Question 22

what would a normal physical exam for the respiratory section look like

Answer 22

normal respiratory effort. clear to auscultation, no wheezing, rales, or rhonchi

Question 23

what would a normal physical exam for the cardiovascular section look like

Answer 23

normal rate, regular rhythm, no murmurs, rubs or gallops

Question 24

what would a normal physical exam for the gastrointestinal section look like

Answer 24

soft, no tenderness to palpitation, no guarding or rebound. no organomegaly. normal bowel sounds

Question 25

what would a normal physical exam for the musculoskeletal section look like

Answer 25

no obvious deformities. no significant edema

Question 26

what would a normal physical exam for the skin section look like

Answer 26

no obvious rashes

Question 27

what would a normal physical exam for the neurological section look like

Answer 27

alert and oriented x3. normal strength. no focal neurological deficit

Question 28

what would a normal physical exam for the psychiatric section look like

Answer 28

normal affect