Course 1: ED Flow Flashcards
Objective
Fact
Chief complaint
The main reason for the patient’s ED visit
Medical decision making
The physician’s thought process
Pain
Patient’s feeling
Tenderness
Physician’s assessment
Benign
Normal, nothing of concern
Distress
The doctor’s judgment of discomfort
Febrile
The state of having a fever, concerning for infection
Acute
New onset, likely concerning
Chronic
Long-standing, not of direct concern
Baseline
An individual’s normal state of being
Auscultation
Listening with a stethoscope
Palpation
The act of pressing on an area by the doctor
Inpatient
Admitted to th hospital overnight
Outpatient
Seen and sent home the same day
What is a scribe?
An unlicensed person performing documentation and other non-clinical tasks under the direction of a licensed independent practitioner
Scribes can….
- document history, physical exam, results, procedures, and physician consults
- access and document lab results and radiology findings
- access and display X-rays for the physician to review
- locate and obtain PMHx, previous charts, past results, and recent studies
- record physician interpretations of X-Rays and ECG’s
Scribes cannot….
- 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
Charge nurse
Manages the ED patient flow
Mid-level provider
Nurse practitioner (LNP) or Physician assistant (PA) that works under the supervision of a physician to diagnose and treat patients
ED Nurse
Records medical histories, symptoms, monitors the patient, starts IVs, administers medications, and assists with procedures
Respiratory therapist
Administers “breathing treatments” and assists with managing a patient’s airway
ED Tech
Helps the nurse and assists with procedures
Unit secretary
Places physician’s orders, answers phone calls, pages other specialists/doctors, and organize the patient’s paperwork
Scribe
Documents the patient’s visit on behalf of the physician
ED Flow
- Check in and chief complaint
- physician assessment
- objective orders and results
- medical decision making
- Disposition
Two ways to enter a hospital
- walk-in
* EMS (ambulance)
What happens at the triage?
- chief complaint
- vital signs
- level of acuity (5 low to 1 high)9
What are the vital signs?
Heart rate (HR), blood pressure (BP), respiratory rate (RR), temperature (T), oxygen saturation SAO2
What happens in a nurse assessment?
- Confirm chief complaint
- review allergies
- brief past medical history
What happens at history and physical?
Subjective:
HPI and ROS
Past history:
PMHx, PSHx
FHx, SHx
Objective: PE
Differential Dx:
Based on History and physical, 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
Subjective
Feeling
Physician orders
- lab studies
- imaging studies
- procedures
- medications
Final Dx
The physician uses MDM and reviews specific results that can rule out differential diagnoses (DDx) to reach the Final Diagnosis
3 options for disposition
- discharge
- admittance
- transfer
General documentation template and which ones are subjective and objective
- HPI (sub)
- ROS (sub)
- past history
- PE (ob)
- Ed course (ob)
- disposition
Where to document patient complaint?
HPI or ROS
Where to document past Dx or surgery?
Past history
Where to document physician’s observation?
PE
Where to document objective study?
Results/ED course
Where to document re-evaluation?
ED course
Where to document where the pt will go?
Diagnosis and disposition
High blood pressure
Hypertension (HTN)
High cholesterol
Hyperlipidemia (HLD)
Thyroid problem
Hypothyroidism or hyperthyroidism
Diabetes
Diabetes mellitus (DM)
“I only take pills for my diabetes”
Non-insulin dependent diabetes mellitus (NIDDM)
“I take shots (insulin) for my diabetes”
Insulin dependent diabetes mellitus (IDDM)
Heart disease
Usually coronary artery disease (CAD)
Heart attack
Myocardial infarction (MI) and CAD
Heart failure
Congestive heart failure (CHF)
Irregular heartbeat
Atrial Fibrillation (A-Fib)
Murmur
Heart murmur
Episodes of abnormally fast/racing heartbeat
Supraventricle tachycardia (SVT)
Asthma
Asthma
Emphysema/ Chronic Bronchitis
Chronic obstructive pulmonary disease (COPD)
Blood clot in lung
Pulmonary Embolism (PE)
Pneumonia
Pneumonia (PNA)
Reflux
Gastroesophageal reflux disease (GERD)
