Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Scribe America Course Material > Course 1: ED Flow > Flashcards

Course 1: ED Flow Flashcards

1
Q

Objective

A

Fact

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Chief complaint

A

The main reason for the patient’s ED visit

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Medical decision making

A

The physician’s thought process

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Pain

A

Patient’s feeling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Tenderness

A

Physician’s assessment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Benign

A

Normal, nothing of concern

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Distress

A

The doctor’s judgment of discomfort

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Febrile

A

The state of having a fever, concerning for infection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Acute

A

New onset, likely concerning

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Chronic

A

Long-standing, not of direct concern

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Baseline

A

An individual’s normal state of being

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Auscultation

A

Listening with a stethoscope

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Palpation

A

The act of pressing on an area by the doctor

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Inpatient

A

Admitted to th hospital overnight

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Outpatient

A

Seen and sent home the same day

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is a scribe?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Scribes can….

A
  • 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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Charge nurse

A

Manages the ED patient flow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

ED Nurse

A

Records medical histories, symptoms, monitors the patient, starts IVs, administers medications, and assists with procedures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Respiratory therapist

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

ED Tech

A

Helps the nurse and assists with procedures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Unit secretary

A

Places physician’s orders, answers phone calls, pages other specialists/doctors, and organize the patient’s paperwork

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Scribe

A

Documents the patient’s visit on behalf of the physician

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

ED Flow

A
  • Check in and chief complaint
  • physician assessment
  • objective orders and results
  • medical decision making
  • Disposition
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Two ways to enter a hospital

A
  • walk-in

* EMS (ambulance)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What happens at the triage?

A
  • chief complaint
  • vital signs
  • level of acuity (5 low to 1 high)9
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What are the vital signs?

A

Heart rate (HR), blood pressure (BP), respiratory rate (RR), temperature (T), oxygen saturation SAO2

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What happens in a nurse assessment?

A
  • Confirm chief complaint
  • review allergies
  • brief past medical history
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What happens at history and physical?

A

Subjective:
HPI and ROS

Past history:
PMHx, PSHx
FHx, SHx

Objective: PE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Differential Dx:

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Subjective

A

Feeling

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Physician orders

A
  • lab studies
  • imaging studies
  • procedures
  • medications
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Final Dx

A

The physician uses MDM and reviews specific results that can rule out differential diagnoses (DDx) to reach the Final Diagnosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

3 options for disposition

A
  • discharge
  • admittance
  • transfer
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

General documentation template and which ones are subjective and objective

A
  • HPI (sub)
  • ROS (sub)
  • past history
  • PE (ob)
  • Ed course (ob)
  • disposition
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Where to document patient complaint?

A

HPI or ROS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

Where to document past Dx or surgery?

A

Past history

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

Where to document physician’s observation?

A

PE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

Where to document objective study?

A

Results/ED course

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

Where to document re-evaluation?

A

ED course

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

Where to document where the pt will go?

A

Diagnosis and disposition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

High blood pressure

A

Hypertension (HTN)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

High cholesterol

A

Hyperlipidemia (HLD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

Thyroid problem

A

Hypothyroidism or hyperthyroidism

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

Diabetes

A

Diabetes mellitus (DM)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

“I only take pills for my diabetes”

A

Non-insulin dependent diabetes mellitus (NIDDM)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

“I take shots (insulin) for my diabetes”

A

Insulin dependent diabetes mellitus (IDDM)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

Heart disease

A

Usually coronary artery disease (CAD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

Heart attack

A

Myocardial infarction (MI) and CAD

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

Heart failure

A

Congestive heart failure (CHF)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

Irregular heartbeat

A

Atrial Fibrillation (A-Fib)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

Murmur

A

Heart murmur

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

Episodes of abnormally fast/racing heartbeat

A

Supraventricle tachycardia (SVT)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

Asthma

A

Asthma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

Emphysema/ Chronic Bronchitis

A

Chronic obstructive pulmonary disease (COPD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

Blood clot in lung

A

Pulmonary Embolism (PE)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

Pneumonia

A

Pneumonia (PNA)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

Reflux

A

Gastroesophageal reflux disease (GERD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

Ulcer

A

Gastric ulcer or peptic ulcer disease

62
Q

Pancreatitis

A

Pancreatitis

63
Q

Hepatitis

A

Hepatitis (A,B or C)

64
Q

Diverticulitis

A

Diverticulitis

65
Q

Crohn’s/UC

A

Crohn’s disease or ulcerative colitis

66
Q

Irritable bowel

A

Irritable bowel syndrome (IBS)

67
Q

Bladder infection

A

Urinary tract infection (UTI)

68
Q

Kidney infection

A

Pyelonephritis (Pyelo)

69
Q

Kidney stones

A

Renal calculi

70
Q

“I’m on dialysis”

A

Chronic renal failure (CRF) or end stage renal disease (ESRD) on dialysis

71
Q

Enlarged prostate

A

Benign prostate hypertrophy (BPH)

72
Q

G.P.A. (Gynecology)

A

G: number of pregnancies
P: number of live births (viable children)
A: number of miscarriages or abortions

73
Q

Stroke

A

Cerebrovascular Accident (CVA)

74
Q

Mini-Stroke

A

Transient Ischemic attack (TIA)

75
Q

Seizures

A

Seizure disorder/epilepsy

76
Q

Brain bleed

A

Hemorrhagic (CVA)

77
Q

Bipolar

A

Bipolar disorder

78
Q

Schizophrenia

A

Schizophrenia

79
Q

“I drink a lot”

A

ETOH abuse or alcoholism

80
Q

“I do drugs”

A

Substance abuse

81
Q

“Blood clot in my leg”

A

Lower extremity deep vein thrombosis (DVT)

82
Q

“Bulge in my aorta” or “Triple A”

A

Abdominal aortic aneurysm (AAA)

83
Q

“Bad blood flow to my legs”

A

Peripheral vascular disease (PVD)

84
Q

“Numbness in my legs”

A

Peripheral neuropathy

85
Q

Low back pain

A

Chronic low back pain

86
Q

Bulging/herniated disc

A

Degenerative Disc disease (DDD)

87
Q

Arthritis

A

Osteoarthritis (OA) or Rheumatoid Arthritis (RA)

88
Q

Joint pain (chronic)

A

Degenerate joint disease (DJD)

89
Q

Weak/fragile bones

A

Often Osteoporosis

90
Q

Cancer that spread to my…

A

Type/ cancer/ with metastases to the…

91
Q

Chemo

A

Chemotherapy

92
Q

Radiation

A

Radiation therapy

93
Q

They cut it out

A

Status-post surgical resection

94
Q

It’s gone

A

In remission

95
Q

-ectomy

A

Removal surgery

96
Q

-itis

A

Inflammation

97
Q

-pathy

98
Q

-osis

A

Disease/condition

99
Q

Tonsils removed

A

Tonsillectomy

100
Q

Adenoids removed

A

Adenoidectomy

101
Q

Ear tubes

A

Pressure equalizer (P.E.) Tubes

102
Q

Heart bypass

A

Coronary artery bypass graft (CABG) ➡️ PMHx CAD

103
Q

Stents

A

Coronary stents ➡️ PMHx CAD

104
Q

Heart cath

A

Cardiac catheterization

105
Q

Balloon

A

Angioplasty ➡️ PMHx CAD

106
Q

Valve surgery

A

Valve repair or replacement (Bovine vs. Mechanical)

107
Q

Pacer

108
Q

Defibrillator

A

Automatic implanted cardiac defibrillator (AICD)

109
Q

Surgery for Afib

A

Afib s/p cardiac ablation

110
Q

Breast removal

A

Mastectomy

111
Q

Hole in my neck

A

Tracheostomy (“trach”)

112
Q

Part of my lung removed

A

Partial lobectomy

113
Q

Appendix removed

A

Appendectomy

114
Q

Gallbladder removed

A

Cholecystectomy

115
Q

Hernia repair

A

Herniorrhaphy

116
Q

Part of my colon removed

A

Partial colectomy

117
Q

Bag to collect stool

118
Q

Spleen removed

A

Splenectomy

119
Q

Stomach stapled

A

Gastric bypass

120
Q

Exploratory

A

Exploratory laproscopy (ExLap)

121
Q

Kidney removed

A

Nephrectomy

122
Q

Uterus removed

A

Hysterectomy (partial vs. total)

123
Q

Ovary removed

A

Oophorectomy

124
Q

Ovary and Fallopian tubes removed

A

Salpingo-oophorectomy

125
Q

Tubes tied

A

Tubal ligation (female) or vasectomy (male)

126
Q

C-Section

A

Cesarean section

127
Q

Prostate removed

A

Prostatectomy (TURP)

128
Q

Uterine product removed

A

Dilation and curettage (D and C)

129
Q

Neck artery cleaned

A

Carotid endarterectomy

130
Q

Brain surgery

A

Craniotomy (brain bleed vs. brain CA)

131
Q

Shunt

A

Ventriculoperitoneal (VP) shunt

132
Q

Dialysis fistula

A

AV (arteriovenous) fistula

133
Q

Dialysis graft

134
Q

PICC line

A

Peripherally inserted central catheter (PICC)

135
Q

Port

A

Port-a-cath or Medi-Port

136
Q

Clot filter (lower abdomen)

A

IVC (inferior vena cava) Filter

137
Q

Clot filter (leg)

A

Greenfield filter

138
Q

Leg amputated

A

Above knee amputation (AKA)

Below knee amputation (BKA)

139
Q

Joint repair

A

Arthroplasty

140
Q

Metal plates/pins

141
Q

Neck fused

A

Cervical spinal fusion

142
Q

Back fused

A

Lumbar spinal fusion

143
Q

Hip surgery

A

Open reduction with internal fixation (ORIF)

144
Q

True allergy

A

Rash, itching, swelling, difficulty breathing

145
Q

Adverse reaction

A

Anything that is not a true allergy

146
Q

FHx General

147
Q

FHx cardiac

A

MI/CAD less than 55 y/o

148
Q

NKDA

A

No known drug allergies

149
Q

Bruising

A

Ecchymosis

150
Q

Redness

Scribe America Course Material (5 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions