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Scribe > Course 1: ED Flow > Flashcards

Course 1: ED Flow Flashcards

1
Q

What is a scribe?

A

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

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2
Q

Scribes CAN…

A
  1. Document history, PE, results, procedures, and physician consults.
  2. Access and document laboratory results and radiology findings.
  3. Access and display X-rays for the physician to review.
  4. Locate and obtain PMHx and recent studies.
  5. Record physician interpretations of X-Rays and ECG’s.
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3
Q

Scribes CANNOT…

A
  1. Touch patients.
  2. Write orders or prescriptions.
  3. Give verbal orders.
  4. Do anything that affects patients health.
  5. Sign or authenticate any chart or record.
  6. Handle bodily fluids or specimens.
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4
Q

Subjective

A

Feeling

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5
Q

Objective

A

Fact

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6
Q

Chief Complaint

A

The main reason for the patient’s ED visit.

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7
Q

Medical Decision Making

A

The physician’s thought process.

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8
Q

Pain

A

Patient’s feeling.

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9
Q

Tenderness

A

Physician’s assessment.

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10
Q

Benign

A

Normal, nothing of concern.

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11
Q

Distress

A

The doctor’s judgement of discomfort.

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12
Q

Febrile

A

The state of having fever, concerning for infection.

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13
Q

Acute

A

New onset, likely concerning.

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14
Q

Chronic

A

Long-standing, not of direct concern

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15
Q

Baseline

A

An individual’s normal state of being.

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16
Q

Auscultation

A

Listening with a stethoscope.

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17
Q

Palpation

A

The act of pressing on an area.

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18
Q

Inpatient

A

Admitted to the hospital overnight.

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19
Q

Outpatient

A

Seen and sent home the same day.

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20
Q

People in ED

A
  1. Charge Nurse
  2. Mid-Level Provider (LPN or PA)
  3. ED Nurse
  4. Respiratory Therapist (RT)
  5. ED Tech
  6. Unit Secretary
  7. Scribe
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21
Q

ED Flow

A
  1. Check in and Chief Complaint
  2. Physician Assessment
  3. Objective Orders and Results
  4. Medical Decision Making
  5. Disposition
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22
Q

ED Flow: Before Orders

A
  1. Walk-In or EMS
  2. Triage
  3. Bed Placement
  4. History and Physical
  5. Physicians orders
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23
Q

ED Flow: After Orders

A
  1. Differential Dx
  2. Physician orders
  3. Laboratory studies, imaging studies, procedures, medications.
  4. Results and ED course.
  5. Final Dx
  6. Disposition
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24
Q

Triage

A

Chief Complaint
Vital Signs
Level of Acuity

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25
Q

Vital Signs

A 
HR
BP
RR
T
SaO2
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26
Q

Nurse Assessment

A
  1. Confirm chief complaint
  2. Review allergies
  3. Brief PMHx
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27
Q

History and Physical

A
  1. Subjective (HPI & ROS)
  2. Past History (PMHx, PSHx, FHx, SHx)
  3. Objective (PE)
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28
Q

Differential Dx

A

A list of things that may be causing the pt’s subjective symptoms.

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29
Q

Results and ED Course

A

Patient re-evaluations. Consults with specialists.

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30
Q

Disposition

A
  1. Discharge Home
  2. Admit for further care
  3. Transfer to another facility
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31
Q

General Documentation Template

A
  1. HPI (story and context of chief complaint)
  2. ROS (positives and negatives)
  3. Past History (PMHx, PSHx, SHx, FHx)
  4. PE (physician’s findings)
  5. ED Course (Objective results)
  6. Disposition ( discharge, admit, transfer)
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32
Q

High blood pressure

A

Hypertension (HTN)

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33
Q

High cholesterol

A

Hyperlipidemia (HLD)

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34
Q

Thyroid problem

A

Usually Hypothyroidism, sometimes Hyperthyroidism

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35
Q

Diabetes

A

Diabetes Mellitus (DM)

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36
Q

“I can only take pills for my diabetes”

A

Non-Insulin Dependent Diabetes Mellitus (NIDDM)

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37
Q

“I take shots (insulin) for my diabetes”

A

Insulin Dependent Diabetes Mellitus (IDDM)

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38
Q

Heart disease

A

Usually Coronary Artery Disease (CAD)

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39
Q

Heart attack

A

Myocardial Infarction (MI) and CAD

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40
Q

Heart failure

A

Congestive Heart Failure (CHF)

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41
Q

Irregular heartbeat

A

Atrial Fibrillation (A-Fib)

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42
Q

Murmur

A

Heart murmur

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43
Q

Episodes of abnormally fast/ racing heartbeat

A

Supraventricular Tachycardia (SVT)

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44
Q

Asthma

A

Asthma

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45
Q

Emphysema/ Chronic Bronchitis

A

Chronic Obstructive Pulmonary Disease (COPD)

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46
Q

Blood clot in lung

A

Pulmonary Embolism (PE)

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47
Q

Pneumonia

A

Pneumonia (PNA)

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48
Q

Reflux

A

Gastroesophageal Reflux Disease (GERD)

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49
Q

Ulcer

A

Gastric Ulcer or Peptic Ulcer Disease (PUD)

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50
Q

Pancreatitis

A

Pancreatitis

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51
Q

Hepatitis

A

Hepatitis A/B/C

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52
Q

Diverticulitis

A

Diverticulitis

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53
Q

Crohn’s /UC

A

Crohn’s Disease or Ulcerative Colitis

54
Q

Irritable bowel

A

Irritable Bowel Syndrome (IBS)

55
Q

Bladder infection

A

Urinary Tract Infection (UTI)

56
Q

Kidney infection

A

Pyelonephritis (Pyelo)

57
Q

Kidney stones

A

Renal calculi/ Nephrolithiasis

58
Q

“I’m on dialysis”

A

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

59
Q

Enlarged prostate

A

Benign Prostate Hypertrophy (BPH)

60
Q

Stroke

A

Cerebrovascular Accident (CVA)

61
Q

Mini-stroke

A

Transient Ischemic Attack (TIA)

62
Q

Seizures

A

Seizure disorder/Epilepsy

63
Q

Brain bleed

A

Hemorrhagic CVA

64
Q

Bipolar

A

Bipolar disorder

65
Q

Schizophrenia

A

Schizophrenia

66
Q

“I drink a lot”

A

ETOH abuse or Alcoholism

67
Q

“I do drugs”

A

Substance Abuse

68
Q

“Blood clot in my leg”

A

Lower Extremity Deep Vein Thrombosis (DVT)

69
Q

“Bulge in my aorta” or “Triple A”

A

Abdominal Aortic Aneurysm (AAA)

70
Q

“Bad blood flow to my legs”

A

Peripheral Vascular Disease (PVD)

71
Q

“Numbness in my legs”

A

Peripheral Neuropathy

72
Q

Low back pain

A

Chronic Low Back Pain

73
Q

Bulging/Herniated disc

A

Degenerative Disc Disease (DDD)

74
Q

Arthritis

A

Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA)

75
Q

Joint pain (chronic)

A

Degenerative Joint Disease (DJD)

76
Q

Weak/fragile bones

A

Often Osteoporosis

77
Q

Cancer

A

Cancer or Carcinoma (CA): brain, breast, lung, colon, prostate, ovarian, skin, bone, leukemia or lymphoma.

78
Q

Spread to my…

A

With metastases to the …

79
Q

Chemo

A

Chemotherapy

80
Q

Radiation

A

Radiation therapy

81
Q

They cut it out

A

Status-post surgical resection

82
Q

It’s gone

A

In remission

83
Q

Tonsils removed

A

Tonsillectomy

84
Q

Adenoids removed

A

Adenoidectomy

85
Q

Ear tubes

A

Pressure Equalizer (P.E.) Tubes

86
Q

Heart by pass

A

Coronary Artery Bypass Graft (CABG) –> PMHx CAD

87
Q

Stents

A

Coronary Stents –> PMHx CAD

88
Q

Heart Cath

A

Cardiac catheterization

89
Q

Balloon

A

Angioplasty –> PMHx CAD

90
Q

Valve surgery

A

Valve repair or replacement (Bovine vs. Mechanical)

91
Q

Pacer

A

Pacemaker

92
Q

Defibrillator

A

Automatic Implanted Cardiac Defibrillator (AICD)

93
Q

Surgery for Afib

A

Afib s/p cardiac ablation

94
Q

Breast removal

A

Mastectomy

95
Q

Hole in my neck

A

Tracheostomy (commonly called “trach”)

96
Q

Part of my lung removed

A

Partial lobectomy

97
Q

Appendix removed

A

Appendectomy

98
Q

Gallbladder removed

A

Cholecystectomy

99
Q

Hernia repair

A

Herniorrhaphy

100
Q

Part of my colon removed

A

Partial colectomy

101
Q

Bag to collect stool

A

Colostomy

102
Q

Spleen removed

A

Splenectomy

103
Q

Stomach stapled

A

Gastric bypass

104
Q

Exploratory

A

Exploratory Laproscopy (ExLap)

105
Q

Kidney removed

A

Nephrectomy

106
Q

Uterus removed

A

Hysterectomy (partial vs. total)

107
Q

Ovary removed

A

Oophorectomy

108
Q

Ovary and Fallopian tubes removed

A

Salpingo-oophorectomy

109
Q

Tubes tied

A

Tubal ligation (female) or Vasectomy (male)

110
Q

C-Section

A

Cesarean Section

111
Q

Prostate removed

A

Prostatectomy (most often Trans-Urethral Removal of the Prostate, or TURP)

112
Q

Uterine product removed

A

Dilation and Curettage (D&C)

113
Q

Neck artery cleaned

A

Carotid Endarterectomy

114
Q

Brain surgery

A

Craniotomy (brain bleed vs. brain CA)

115
Q

Shunt

A

Ventriculoperitoneal (VP) Shunt

116
Q

Dialysis fistula

A

AV (arteriovenous) Fistula

117
Q

Dialysis graft

A

AV Graft

118
Q

PICC Line

A

Peripherally Inserted Central Catheter (PICC)

119
Q

Port

A

Port-a-cath or Medi-Port

120
Q

Clot filter (lower abdomen)

A

IVC (inferior vena cava) Filter

121
Q

Clot filter (leg)

A

Greenfield Filter

122
Q

Leg amputated

A

Above Knee Amputation (AKA)

Below Knee Amputation (BKA)

123
Q

Joint repair

A

Arthroplasty

124
Q

Metal plates/pins

A

Hardware

125
Q

Neck fused

A

Cervical spinal fusion

126
Q

Back fused

A

Lumbar spinal fusion

127
Q

Hip surgery

A

Open Reduction with Internal Fixation (ORIF)

128
Q

True Allergy

A

Rash
Itching
Swelling
Difficulty breathing

129
Q

Family History

A 
General 
Cardiac
Pulmonary 
Gastrointestinal 
Neurological
Miscellaneous
130
Q

Social History

A 
Tobacco Use 
Alcohol Use 
Illicit Drug Use
Occupation 
Living Circumstances

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