Course 1: Emergency Department Flow Flashcards
subjective v objective
feeling v fact
chief complaint
main reason for the patient’s visit
medical decision making
physician’s thought process
pain v tenderness
patient’s feeling v physician’s assessment
benign
normal
distress
doctor’s judgment of discomfort
febrile
state of having a fever, concerning for infection
acute
new onset, likely concerning
chronic
long standing, not of direct concern
baseline
individual’s normal state of being
auscultation
listening with a stethoscope
palpation
pressing on an area (by doctor)
inpatient
admitted to hospital overnight
outpatient
seen and sent home same day
Charge Nurse
manages the ED patient flow
mid level provider
nurse practitioner (LNP) or a PA that works under the supervision of a physician to diagnose and treat patients
ED Nurse
record medical histories, symptoms, monitors the patient, starts IVs, administers medications, and assists with procedures
Respiratory Therapist (RT)
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 organizes the patient’s paperwork
Scribe
documents the patient’s visit on behalf of the physician
ED Flow
check in/chief complaint -> physician assessment -> objective orders and results -> medical decision making -> disposition
ED Documentation Template
HPI (chief complaint)
ROS (head to toes checklist of other unrelated concerns)
Past Hx (medical, surgical, social, family)
PE (initial objective facts)
ED Course (results, reevaluations, consultations, events)
Diagnosis and Disposition
Vital Signs (5)
BP HR Respiratory Rate Temp O2 Sat
True Allergy
causes a rash, itching, swelling, or difficulty breathing. Otherwise, it is an adverse reaction.
FHx - age of onset of disease
FHx important to know for these diseases General (3) Cardiac Pulmonary (2) GI (2) Neurological (3) Misc (2)
General : HTN, CA, DM Cardiac: MI/CAD Pulmonary: PE, Asthma GI: Crohn's, IBS Neuro: CVA, Aneurysm, Seizures Misc: Sickle cell anemia, DVT
Social Hx
tobacco use, alcohol use, illicit drug use, occupation, living circumstances
pediatrics- caretaker, attends school/daycare, has brothers/sisters, second hand smoke exposure, immunizations
