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Scribe terms > Course 1 > Flashcards

Course 1 Flashcards

1
Q

Subjective vs objective

A

Feeling vs Fact

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2
Q

Cheif complaint

A

the main reason for the patient’s ED visit

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3
Q

Medical Decision Making

A

Physician’s thought process

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4
Q

Pain vs tenderness

A

Patient’s feeling vs. physician’s assessment

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5
Q

benign

A

normal, nothing of concern

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6
Q

Distress

A

the doctor’s judgement of discomfort

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7
Q

febrile

A

the state of having a fever, concerning for infection

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8
Q

acute

A

new onset, likely concerning

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9
Q

chronic

A

long-standing, not of direct concern

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10
Q

baseline

A

an individual’s normal state of being

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11
Q

auscultation

A

listening with a stethoscope

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12
Q

palpation

A

the act of pressing on an area (by the doctor)

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13
Q

inpatient

A

admitted to the hospital overnight

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14
Q

outpatient

A

seen and sent home the same day

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15
Q

What is a scribe (specifically Emergency physician scribe?

A

An unlicensed person performing documentation and other non-clinical tasks under the direction of a licensed independent practitioner.

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16
Q

Scribes can document..

A

history, PE, results, procedures, and physician consults.

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17
Q

scribes can access and document…

A

laboratory results and radiology findings

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18
Q

scribes can access and display

A

X-rays for the physician to review

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19
Q

Scribes can locate and obtain..

A

PMHx, previous charts, past results, and recent studies

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20
Q

Scribes can record…

A

physician interpretations of X-Rays and ECGs

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21
Q

Scribes can’t…

A

touch patients, write orders or prescriptions, give verbal orders, partake in anything that may affect patient health or outcome, sign/authenticate any chart or record, handle bodily fluids or specimens.

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22
Q

charge nurse

A

Manages the ED patient flow

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23
Q

Mid-level provider

A

Nurse practitioner (LNP) or Physician assistant (PA) that works under the supervision of a physician to diagnose and treat patients

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24
Q

ED nurse

A

records medical histories, symptoms, monitors the patient, starts IVs, administer medication, and assists with procedures.

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25
Q

Respiratory therapist (RT)

A

Administers “breathing treatments” and assists with managing a patient’s airway.

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26
Q

ED tech

A

helps the nurse and assists with procedures.

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27
Q

Unit secretary

A

places physician’s orders, answer phone calls, pages other specialists/doctors, and organizes the patient’s paperwork.

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28
Q

Scribe

A

documents the patient’s visit on behalf of the physician.

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29
Q

Job of emergency physician is?

A

to use a patient’s subjective complaints as a guide for obtaining objective facts that lead to an accurate diagnosis.

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30
Q

ED flow overview

A

check in and chief complaint-physician assessment- objective orders and results- medical decision making- disposition

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31
Q

ED flow before orders

A

Walk-in/EMS - triage - bed placement- nurse assessment - H & P - physician orders

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32
Q

ED flow after orders

A

physician orders- ruling out differentials - results and ED course- Final Dx- disposition

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33
Q

walk-in/EMS

A

waiting room/ambulance bay

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34
Q

triage

A

chief complaint, vital signs, Level of acuity

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35
Q

Vital signs

A

HR, BP, RR, T, SaO2

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36
Q

Nurse assessment

A

confirm chief complaint, review allergies, brief past medical history

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37
Q

History and physical (H& P)

A

subjective (HPI, ROS), past history (PMHx, PSHx, FHx, SHx), objective (PE)

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38
Q

Differential Dx

A

Based on the H&P, the physician generates a list of things that may be causing the pt’s subjective symptoms. Then the doctor places orders to “rule out” each differential.

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39
Q

physician orders

A

Laboratory studies, imaging, procedures, medications

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40
Q

Results and ED course

A

Patient re-evaluations. Consults with specialists

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41
Q

Final Dx

A

By using Medical Decision Making (MDM) the physician reviews specific
results that can rule out Differential Diagnoses (DDx) to reach the Final Diagnosis (Dx)

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42
Q

MDM

A

Medical decision making

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43
Q

DDx

A

differential diagnosis

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44
Q

HPI (history of present illness)

A

The story and context of the Chief Complaint

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45
Q

review of systems (ROS)

A

A head-to-toe list of positives and negatives

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46
Q

Past History

A

PMHx, PSHx, SHx, FHx

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47
Q

Physical Exam (PE)

A

The physician’s objective findings

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48
Q

ED Course

A

Objective results (Labs, Imaging, Re-Evals, Consults, Procedures)

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49
Q

Disposition

A

Discharge, Admit, Transfer

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50
Q

ED chart layout

A

Subjective complaints(HPI and ROS), Past history, Objective Evaluation (PE and ED course), Dx and disposition

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51
Q

What is the name of your hospital’s documentation system?

A

Epic

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52
Q

Vital signs (scribes part)

A

obtained in nurse triage, but documentation in chart is your job, and doc of changes

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53
Q

high blood pressure

A

Hypertension (HTN)

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54
Q

High cholesterol

A

Hyperlipidemia (HLD)

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55
Q

Thyroid problem

A

Usually hypothyroidism, sometimes hyperthyroidism

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56
Q

diabetes

A

DM

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57
Q

I take pills for Diabetes

A

NIDDM

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58
Q

I take shots of insulin for diabetes

A

IDDM

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59
Q

Heart disease

A

CAD (coronary artery disease)

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60
Q

heart failure

A

congestive heart failure (CHF)

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61
Q

irregular heart beat

A

A- fib

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62
Q

Murmur

A

hear murmur

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63
Q

Episodes of abnormally fast/ racing heartbeat

A

Supraventricular Tachycardia (SVT)

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64
Q

asthma

A

asthma

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65
Q

Emphysema/ Chronic Bronchitis

A

Chronic Obstructive Pulmonary Disease (COPD)

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66
Q

blood clot in lung

A

Pulmonary embolism (PE)

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67
Q

Pneumonia

A

PNA

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68
Q

reflux

A

Gastroesophageal Reflux Disease (GERD)

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69
Q

pancreatitis

A

pancreatitis

70
Q

Hepatitis

A

A, B, Or C

71
Q

Diverticulitis

A

diverticulitis

72
Q

Crohn’s/UC

A

Crohn’s Disease or Ulcerative Colitis

73
Q

irratable bowel

A

Irritable Bowel Syndrome (IBS)

74
Q

bladder infection

A

UTI

75
Q

kidney infection

A

pyelonephritis (pyelo)

76
Q

kidney stones

A

Renal calculi

77
Q

I’m on dialysis

A

Chronic Renal Failure (CRF) or End Stage Renal Disease (ESRD) on dialysis

78
Q

enlarged prostate

A

Benign Prostate Hypertrophy (BPH)

79
Q

Chronic renal failure

A

CRF

80
Q

End stage renal disease

A

ESRD

81
Q

benign prostate hypertrophy

A

BPH

82
Q

Gynecological PMHx

A

G/P/A

83
Q

G: gravida

A

is the total number of times the patient has been pregnant

84
Q

P: para

A

is the number of lives births (viable children) that the pt has had

85
Q

Abortion A:

A

is the total number of miscarriages or elective abortions

86
Q

stroke

A

CVA cerebrovacular accident

87
Q

mini-stroke

A

Transient Ischemic Attack (TIA)

88
Q

seizures

A

Seizure disorder/Epilepsy

89
Q

brain bleed

A

Hemorrhagic CVA

90
Q

bipolar

A

bipolar disorder

91
Q

schizophrenia

A

schizophrenia

92
Q

i drink a lot

A

ETOH abuse or Alcoholism

93
Q

“I do drugs”

A

substance abuse

94
Q

blood clot in my leg

A

Lower Extremity Deep Vein Thrombosis (DVT)

95
Q

“Bulge in my aorta” or “Triple A”

A

Abdominal Aortic Aneurysm (AAA)

96
Q

“Bad blood flow to my legs

A

Peripheral Vascular Disease (PVD)

97
Q

“Numbness in my legs”

A

Peripheral Neuropathy

98
Q

low back pain

A

chronic low back pain

99
Q

bulging/heriniated disc

A

Degenerative Disc Disease (DDD)

100
Q

arthritis

A

Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA)

101
Q

Joint pain (chronic)

A

Degenerative Joint Disease (DJD)

102
Q

Weak/fragile bones

A

often osteoporosis

103
Q

Cancer

A

Cancer or Carcinoma (CA): Brain, Breast, Lung, Colon, Prostate, Ovarian, Skin, Bone, Leukemia, or Lymphoma

104
Q

spread to my…

A

with metastases to the

105
Q

chemo

A

chemotherapy

106
Q

radiation

A

radiation therapy

107
Q

they cut it out

A

Status-post surgical resection

108
Q

it’s gone

A

in remission

109
Q

Tonsils removed

A

Tonsillectomy

110
Q

Adenoids removed

A

Adenoidectomy

111
Q

Ear tubes

A

Pressure Equalizer (P.E.) Tubes

112
Q

Heart Bypass

A

CABG - PMHx CAD

113
Q

stents

A

Coronary stents- PMHx CAD

114
Q

Heart Cath

A

Cardiac Catherization

115
Q

Balloon

A

Angioplasty- PMHx CAD

116
Q

Valve surgery

A

valve repair or replacement (Bovine vs. Mechanical)

117
Q

Pacer

A

PAcemaker

118
Q

Defibrillator

A

Automatic Implanted Cardiac Defibrillator (AICD)

119
Q

Surgery for AFib

A

Afib s/p cardiac ablation

120
Q

breast removal

A

mastectomy

121
Q

hole in my neck

A

tracheostomy (trach)

122
Q

part of my lung removed

A

Partial lobectomy

123
Q

Appendix removed

A

appendectomy

124
Q

gallbladder removed

A

cholecystectomy

125
Q

hernia repair

A

herniorrhaphy

126
Q

part of my colon removed

A

partial colectomy

127
Q

bag to collect stool

A

colostomy

128
Q

spleen removed

A

splenectomy

129
Q

stomach stapled

A

gastric bypass

130
Q

exploratory

A

exploratory Laproscopy (ExLap)

131
Q

kidney removed

A

nephrectomy

132
Q

uterus removed

A

hysterectomy (partial vs. total)

133
Q

ovary removed

A

oophorectomy

134
Q

ovary and fallopian tubes removed

A

salpingo-oophorectomy

135
Q

tubes tied

A

tubal ligation (female) or Vasectomy (male)

136
Q

C-section

A

cesarean section

137
Q

prostate removed

A

prostatectomy (most often trans-urethral removal of the prostate, or TURP)

138
Q

Uterine product removed

A

Dilation and curettage (D&C)

139
Q

Neck artery cleaned

A

Carotid Endarterectomy

140
Q

Brain surgery

A

craniotomy (brain bleed vs. brain CA)

141
Q

Shunt

A

Ventriculoperitoneol (VP) shunt

142
Q

Dialysis fistula

A

AV (arteriovenous fistula)

143
Q

Dialysis graft

A

AV graft

144
Q

PICC line

A

Peripherally inserted central catheter (PICC)

145
Q

Port

A

Port-a-cath or Medi-Port

146
Q

Clot filter (Lower abdomen)

A

IVC (inferior vena cava) Filter

147
Q

Clot filter (leg)

A

greenfield filter

148
Q

leg amuptated

A

Above Knee Amputation (AKA) Below Knee Amputation (BKA)

149
Q

joint repair

A

arthroplasty

150
Q

Metal plates/pins

A

Hardware

151
Q

Neck fused

A

cervical spinal fusion

152
Q

Back fused

A

Lumbar spinal fusion

153
Q

Hip surgery

A

Open Reduction with Internal Fixation (ORIF)

154
Q

Home medications and Allergies

A

Physician will almost always ask pt their home meds and allergies. Home meds entered by nurse, but may be asked to update med list in PMHx. Pay attentions to allergies reviewed.

155
Q

True allergies

A

causes rash, itching swelling, or difficulty reaction

156
Q

not an allergy

A

adverse reaction

157
Q

FHx (Family History)

A

Younger age means higher genetic risk. Older (50+) more due to the environment than genetics. Genetic risk is higher if high frequency of disease in family.

158
Q

FHx General

A

HTN, DM, CA

159
Q

FHx Cardiac

A

MI/CAD less than 55 years old

160
Q

FHx Pulmonary

A

PE, Asthma

161
Q

Gastronintestinal FHx

A

Crohn’s, IBS

162
Q

Neurological FHx

A

CVA, ANeurysm, Seizures

163
Q

Misc. FHx

A

Sickle cell Anemia, DVT

164
Q

Social history (SHx)

A

Tobacco use, Alcohol Use, Illicit Drug Use, Occupation, Living circumstances,

165
Q

Tobacco use SHX

A
  • Smoking status
  • Former (year quit)
  • Never
  • Current (#ppd, #yrs)
  • Second-hand exposure (pediatrics)
  • Chewing tobacco
166
Q

Alcohol Use (ETOH) SHx

A
  • Never
  • Occasionally/socially
  • Daily
  • Chronic alcoholic
  • Number of drinks/day
  • Type of alcohol (beer/wine/liquor)
167
Q

Illicit Drug Use SHx

A 
• Which drug
• Heroin
• Cocaine
• Methamphetamine • THC
• Narcotics
• Route of administration Oral
Inhaled Injected
• Date of last use
168
Q

Occupation SHx

A
  • Employed
  • Unemployed
  • On disability
  • Retired
  • If physician asks specifically about type of work, be sure to document it
169
Q

SHx living circumstances

A
  • Lives alone
  • With family/friends
  • Nursing home/assisted living
  • Hospice
  • Homeless/shelter
170
Q

SHx Pediatrics

A 
• Caretaker (mother, father, etc.)
• Attends daycare
• Attends school
• Has brothers/sisters
• Second-hand smoke exposure
• Immunizations up to date
*unique, kids can't talk

Scribe terms (5 decks)

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