Brainscape's Knowledge GenomeTM

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


See full index

Scribe America Pre-Clinical Training > Course 1: Emergency Department Flow > Flashcards

Course 1: Emergency Department Flow Flashcards

1
Q

subjective vs. objective

A

feeling vs. 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 vs. tenderness

A

patient’s feeling vs. physician’s assessment

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

benign

A

normal, nothing of concern

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

distress

A

the doctor’s judgment of discomfort

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
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
8
Q

acute

A

new onset, likely concerning

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

chronic

A

long standing, not of direct concern

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
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
11
Q

auscultation

A

listening with a stethoscope

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
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
13
Q

inpatient

A

admitted to the hospital overnight

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
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
15
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
16
Q

What are the 5 things scribes CAN do?

A
  1. Document the history, physical exam, 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, previous charts, past results, and recent studies
  5. Record physician interpretations of X-rays and ECG’s
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are the 5 things scribe CAN NOT do?

A
  1. Touch patients
  2. Write orders or prescriptions
  3. Give verbal orders
  4. Partake in any activity that may affect patient health or outcome
  5. Sign or authenticate any chart or record
  6. Handle bodily fluids or specimens
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

charge nurse

A

manages the ED patient flow

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
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
20
Q

ED nurse

A

records medical history, 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
21
Q

respiratory therapist (RT)

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
22
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
23
Q

unit secretary

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
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
25
Q

What is the overview of the ED flow? (5 steps)

A 
Check in and chief complain
Physician assessment
Objective orders and results
Medical decision making
Disposition

(CPOMD = cool physicians often make orders)

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

What is the ED flow BEFORE ORDERS?

A
  1. Walk-In (waiting room) or EMS (ambulance bay)

2A. Triage = chief complaint, vital signs, level of activity (5 low and 1 high)
2B. Vital signs (HR, BP, RR, T, SaO2)

  1. Bed placement
  2. Nurse assessment (confirm chief complaint, review allergies, brief past medical history)
  3. History & Physical (H&P)
    5A. Subjective: HPI, ROS
    5B: Past history (Hx): PMHx, PSHx, FHx, SHx
    5C: Objective: physical examination (PE)
  4. Physician orders
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

What is the ED flow AFTER ORDERS?

A
  1. Differential diagnosis (DDx)
  2. Physician orders
  3. Laboratory studies, imaging studies, procedures, medications
  4. Results & ED course: patient re-evaluations. Consults with specialists.
  5. Final Dx
  6. Disposition: discharge home, admit for further care, transfer to another facility
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What is a differential dx?

A

Based on H&P, the physician generates a list of things that may be causing the patient’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
29
Q

What does the doctor determine the final diagnosis (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)

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

What is the general documentation template?

A

SUBJECTIVE COMPLAINTS:

  1. HPI: history of present illness
  2. ROS: review of systems
  3. Past history: PMHx, PSHx, FHx, SHx

OBJECTIVE EVALUATION:

  1. PE: physical examination
  2. ED course: objective results (labs, imaging, re-evals, consults, procedures)
  3. Disposition: discharge, admit, transfer
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

What is HPI?

A

history of present illness; the story and context of the patient’s chief complaint

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

What is ROS?

A

review of systems; a head-to-toe list of positives and negatives

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

What comprises of the past history?

A

PMHx, PSHx, FHx, SHx

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

What is PE?

A

physical examination; the physician’s objective findings

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

What are the possible disposition options?

A

discharge, admit, transfer

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
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
37
Q

Where to document past diagnosis or surgery

A

past history

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Where to document physician’s observation

A

physical exam

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
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
40
Q

Where to document re-evaluation

A

ED course

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

Where to document where they will go

A

diagnosis & disposition

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

The patient has a history of high cholesterol. Where would this item belong in the chart?

A

past history

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

The patient was given an antiemetic in the ED. Where would this item belong in the chart?

A

ED course

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

The EKG shows normal sinus rhythm. Where would this item belong in the chart?

A

Objective study = ED course

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

The patient came to the ED for chest pain. Where would this item belong in the chart?

A

chief complaint = HPI or ROS

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

The patient also stubbed their toe last week. Where would this item belong in the chart?

A

past history

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

The complete blood count (CBC) shows anemia. Where would this item belong in the chart?

A

objective study = ED course

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

The patient is in no acute distress. Where would this item belong in the chart?

A

physician’s observations = physical exam

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

There is tenderness of the RUQ. Where would this item belong in the chart?

A

physician’s observations = physical exam

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

The patient’s mother has heart disease. Where would this item belong in the chart?

A

past history

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

Patient says: high blood pressure (general past medical history)

A

Scribe writes: hypertension (HTN)

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

Patient says: high cholesterol (general past medical history)

A

Scribe writes: hyperlipidemia (HLD)

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

Patient says; thyroid problem (general past medical history)

A

Scribe writes: usually hypothyroidism, sometimes hyperthyroidism

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

Patient says: diabetes (general past medical history)

A

Scribe writes: diabetes mellitus (DM)

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

Patient says: I only take pills for my diabetes (general past medical history)

A

Scribe writes: non-insulin dependent diabetes mellitus (NIDDM)

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

Patient says: I take shots (insulin) for my diabetes (general past medical history)

A

Scribe writes: insulin dependent diabetes mellitus (IDDM)

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

Patient says: heart disease (cardiovascular PMHx)

A

Scribe writes: usually coronary artery disease (CAD)

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

Patient says: heart attack (cardiovascular PMHx)

A

Scribe writes: myocardial infarction (MI) or CAD

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

Patient says: heart failure (cardiovascular PMHx)

A

Scribe writes: congestive heart failure (CHF)

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

Patient says: irregular heartbeat (cardiovascular PMHx)

A

Scribe writes: atrial fibrillation (A-Fib)

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

Patient says: murmur (cardiovascular PMHx)

A

Scribe writes: heart murmur

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

Patient says: episodes of abnormally fast/racing heartbeat (cardiovascular PMHx)

A

Scribe writes: supraventricular tachycardia (SVT)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

Patient says: asthma (pulmonary PMHx)

A

Scribe writes: asthma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

Patient says: emphysema/chronic bronchitis (pulmonary PMHx)

A

Scribe writes: chronic obstructive pulmonary disease (COPD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

Patient says: blood clot in lung (pulmonary PMHx)

A

Scribe writes: pulmonary embolism (PE)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

Patient says: pneumonia (pulmonary PMHx)

A

Scribe writes: pneumonia (PNA)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

Patient says: reflux (gastrointestinal PMHx)

A

Scribe writes: gastroesophageal reflux disease (GERD)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

Patient says: ulcer (gastrointestinal PMHx)

A

Scribe writes: gastric ulcer or peptic ulcer disease

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

Patient says: pancreatitis (gastrointestinal PMHx)

A

Scribe writes: pancreatitis

70
Q

Patient says: hepatitis (gastrointestinal PMHx)

A

Scribe writes: hepatitis A, hepatitis B, or hepatitis C

71
Q

Patient says: diverticulitis (gastrointestinal PMHx)

A

Scribe writes: diverticulitis

72
Q

Patient says: Crohn’s/UC (gastrointestinal PMHx)

A

Scribe writes: Crohn’s disease or ulcerative colitis

73
Q

Patient says: irritable bowel (gastrointestinal PMHx)

A

Scribe writes: irritable bowel syndrome (IBS)

74
Q

Give example of laboratory studies.

A

Blood work, microscopy, cultures

75
Q

Give examples of imaging studies.

A

X-ray, CT, ultrasound, EKG

76
Q

Give examples of procedures

A

sutures, joint reduction, splints

77
Q

Patient says: bladder infection (genitourinary PMHx)

A

Scribe writes: urinary tract infection (UTI)

78
Q

Patient says: kidney infection (genitourinary PMHx)

A

Scribe writes: pyelonephritis (Pyelo)

79
Q

Patient says: kidney stones (genitourinary PMHx)

A

Scribe writes: renal calculi

80
Q

Patient says: “I’m on dialysis” (genitourinary PMHx)

A

Scribe writes: chronic renal failure (CRF) or end state renal disease (ESRD) on dialysis

81
Q

Patient says: enlarged prostate

A

Scribe writes: benign prostate hypertrophy (BPH)

82
Q

G

A

gravida = total number of times the patient has been pregnant

83
Q

P

A

para = the number of live births (viable children) the patient has had

84
Q

A

A

abortion = the total number of miscarriages or elective abortions

85
Q

How would you document the past history for a patient who is currently pregnant, has been pregnant three times in the past, and has two kids at home?

A

G: 4
P: 2
A: 1

86
Q

Patient says: stroke (neurological PMHx)

A

Scribe writes: ischemic cerebrovascular accident (CVA)

87
Q

Patient says: mini-stroke (neurological PMHx)

A

Scribe writes: transient ischemic attack (TIA)

88
Q

Patient says: seizures (neurological PMHx)

A

Scribe writes: seizure disorder/epilepsy

89
Q

Patient says: brain blood (neurological PMHx)

A

Scribe writes: hemorrhagic CVA

90
Q

Patient says: bipolar (psychological PMHx)

A

Scribe writes: bipolar disorder

91
Q

Patient says: schizophrenia (psychological PMHx)

A

Scribe writes: schizophrenia

92
Q

Patient says: “I drink a lot” (psychological PMHx)

A

Scribe writes: EtOH abuse or alcoholism

93
Q

Patient says: “I do drugs” (psychological PMHx)

A

Scribe writes: substance abuse

94
Q

Patient says: “blood clot in my leg” (vascular PMHx)

A

Scribe writes: lower extremity deep vein thrombosis (DVT)

95
Q

Patient says: “bulge in my aorta” or “triple A” (vascular PMHx)

A

Scribe writes: abdominal aortic aneurysm (AAA)

96
Q

Patient says: “bad blood flow to my legs” (vascular PMHx)

A

Scribe writes: peripheral vascular disease (PVD)

97
Q

Patient says: “numbness in my legs” (vascular PMHx)

A

Scribe writes: peripheral neuropathy

98
Q

Patient says: low back pain (musculoskeletal PMHx)

A

Scribe writes: chronic low back pain

99
Q

Patient says: bulging/herniated disc (musculoskeletal PMHx)

A

Scribe writes: degenerative disc disease (DDD)

100
Q

Patient says: arthritis (musculoskeletal PMHx)

A

Scribe writes: usually osteoarthritis (OA) sometimes rheumatoid arthritis (RA)

101
Q

Patient says: joint pain (chronic) (musculoskeletal PMHx)

A

Scribe writes: degenerative joint disease (DJD)

102
Q

Patient says: weak/fragile bones (musculoskeletal PMHx)

A

Scribe writes: often osteoporosis

103
Q

Patient says: cancer (cancer PMHx)

A

Scribe writes: cancer or carcinoma (CA): brain, breast, lung, colon, prostate, ovarian, skin, bone, leukemia, or lymphoma

104
Q

Patient says: spread to my… I (cancer PMHx)

A

Scribe writes: with metastases to the…

105
Q

Patient says: chemo (cancer PMHx)

A

Scribe writes: chemotherapy

106
Q

Patient says: radiation (cancer PMHx)

A

Scribe writes: radiation therapy

107
Q

Patient says: they cut it out (cancer PMHx)

A

Scribe writes: status-post surgical reaction

108
Q

Patient says: it’s gone (cancer PMHx)

A

Scribe writes: in remission

109
Q

Patient says: tonsils removed (throat PSHx)

A

Scribe writes: tonsillectomy

110
Q

Patient says: adenoids removed (throat PSHx)

A

Scribe writes: adenoidectomy

111
Q

Patient says: ear tubes (throat PSHx)

A

Scribe writes: pressure equalizer (P.E.) tubes

112
Q

Patient says: heart bypass (cardiovascular PSHx)

A

Scribe writes: coronary artery bypass graft (CABG) > PMHx CAD

113
Q

Patient says: stents (cardiovascular PSHx)

A

Scribe writes: coronary stents > PMHx CAD

114
Q

Patient says: heart cath (cardiovascular PSHx)

A

Scribe writes: cardiac catheterization

115
Q

Patient says: balloon (cardiovascular PSHx)

A

Scribe writes: angioplasty > PMHx CAD

116
Q

Patient says: valve surgery (cardiovascular PSHx)

A

Scribe writes: valve repair or replacement (bovine vs. mechanical)

117
Q

Patient says: pacer (cardiovascular PSHx)

A

Scribe writes: pacemaker

118
Q

Patient says: defibrillator (cardiovascular PSHx)

A

Scribe writes: automatic implanted cardiac defibrillator (AICD)

119
Q

Patient says: surgery for A Fib (cardiovascular PSHx)

A

Scribe writes: Afib s/p cardiac ablation

120
Q

Patient says: breast removal (pulmonary/chest PSHx)

A

Scribe writes: mastectomy

121
Q

Patient says: hole in my neck (pulmonary/chest PSHx)

A

Scribe writes: tracheostomy (commonly called a “trach”)

122
Q

Patient says: part of my lung removed (pulmonary/chest PSHx)

A

Scribe writes: partial lobectomy

123
Q

Patient says: appendix removed (gastrointestinal PSHx)

A

Scribe writes: appendectomy

124
Q

Patient says: gallbaldder removed (gastrointestinal PSHx)

A

Scribe writes: cholecystectomy

125
Q

Patient says: hernia repair (gastrointestinal PSHx)

A

Scribe writes: herniorrhaphy

126
Q

Patient says: part of my colon removed (gastrointestinal PSHx)

A

Scribe writes: partial colectomy

127
Q

Patient says: bag to collect stool (gastrointestinal PSHx)

A

Scribe writes: colostomy

128
Q

Patient says: spleen removed (gastrointestinal PSHx)

A

Scribe writes: splenectomy

129
Q

Patient says: stomach staple (gastrointestinal PSHx)

A

Scribe writes: gastric bypass

130
Q

Patient says: exploratory (gastrointestinal PSHx)

A

Scribe writes: exploratory laparoscopy (ExLap)

131
Q

Patient says: kidney removed (genitourinary PSHx)

A

Scribe writes: nephrectomy

132
Q

Patient says: uterus removed (genitourinary PSHx)

A

Scribe writes: hysterectomy (partial vs. total)

133
Q

Patient says: ovary removed (genitourinary PSHx)

A

Scribe writes: oophorectomy

134
Q

Patient says: ovary and fallopian tubes removed (genitourinary PSHx)

A

Scribe writes: salpingo-oophorectomy

135
Q

Patient says: tubes tied (genitourinary PSHx)

A

Scribe writes: tubal ligation (female) or vasectomy (male)

136
Q

Patient says: C-section (genitourinary PSHx)

A

Scribe writes: Caesarean section

137
Q

Patient says: prostate removed (genitourinary PSHx)

A

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

138
Q

Patient says: uterine product removed (genitourinary PSHx)

A

Scribe writes: dilation and curettage (D&C)

139
Q

Patient says: neck artery cleaned (neurological PSHx)

A

Scribe writes: carotid endarterectomy

140
Q

Patient says: brain surgery (neurological PSHx)

A

Scribe writes: crainotomy (brain bleed vs. brain CA)

141
Q

Patient says: shunt (neurological PSHx)

A

Scribe writes: ventriculoperitoneal (VP) shunt

142
Q

Patient says: dialysis fistula (vascular PSHx)

A

Scribe writes: AV (arteriovenous fistula)

143
Q

Patient says: dialysis graft (vascular PSHx)

A

Scribe writes: AV graft

144
Q

Patient says: PICC line (vascular PSHx)

A

Scribe writes: peripherally inserted central catheter (PICC)

145
Q

Patient says: port (vascular PSHx)

A

Scribe writes: Port-a-cath or medi-port

146
Q

Patient says: clot filter (lower abdomen) (vascular PSHx)

A

Scribe writes: IVC (inferior vena cava) filter

147
Q

Patient says: clot filter (leg0 (vascular PSHx)

A

Scribe writes: Greenfield filter

148
Q

Patient says: leg amputated (orthopedic PSHx)

A

Scribe writes: above knee amputation (AKA) or below knee amputation (BKA)

149
Q

Patient says: joint repair (orthopedic PSHx)

A

Scribe writes: arthroplasty

150
Q

Patient says: metal plates/pins (orthopedic PSHx)

A

Scribe writes: hardware

151
Q

Patient says: neck fused (orthopedic PSHx)

A

Scribe writes: cervical spinal fusion

152
Q

Patient says: back fused (orthopedic PSHx)

A

Scribe writes: lumbar spinal fusion

153
Q

Patient says: hip surgery (orthopedic PSHx)

A

Scribe writes: open reduction with internal fixation (ORIF)

154
Q

What is a true allergy?

A

Any medication that causes a rash, itching, swelling, or difficulty breathing. Otherwise, it’s an “adverse reaction”, not a true allergy

155
Q

What is important to family history and why?

A

The age of onset b/c it helps determine the genetic risk factor

156
Q

Younger age of onset means…

A

Higher genetic risk

157
Q

Older age of onset (50 y/o + ) is…

A

more likely due to environment than genetics

158
Q

The genetic risk for the disease is higher if…

A

multiple blood-family members suffer from the same disease

159
Q

FHX general (3)

A

HTN
DM
CA

160
Q

FHx cardiac (1)

A

MI/CAD less than 55 y/o

161
Q

FHx pulmonary (2)

A

PE

Asthma

162
Q

FHx gastrointestinal (2)

A

Crohn’s

IBS

163
Q

FHx neurological (3)

A

CVA
Aneurysm
Seizures

164
Q

FHx miscellaneous (2)

A

Sickle cell anemia

DVT

165
Q

What are the 5 factors pertaining to social history (SHx)?

A 
(TAIL O) 
Tobacco use
Alcohol use (EtOH)
Illicit drug use
Living circumstances
Occuptation
166
Q

What must be recorded in SHx for tabacco use?

A 
Smoking status
> Current (#ppd, #yrs)
> Former (year quit)
> Never
> Second-hand exposure (pediatrics)

Chewing tabacco

167
Q

What must be recorded in SHx for alcohol use?

A 
Never
Occasionally/socially
Daily
Chronic alcoholic 
> Number of drinks/day
> Type of alcohol (beer/wine/liquor)
168
Q

What must be recorded in SHx for illicit drug use?

A 
Which drug
> Heroin
> Cocaine
> Methamphetamine
> THC
> Narcotics

Route of administration
> Oral
> Inhaled
> Injected

Date of last use

169
Q

What must be recorded in SHx for occupation?

A

Employed
Unemployed
On disability
Retired

If a physician asks specifically about type of work, be sure to document it.

170
Q

What must be recorded in SHx for living circumstances?

A 
Lives alone
With family/friends
Nursing home/assisted living
Hospice
Homeless/shelter
171
Q

What must be recorded in SHx for pediatrics? (Unique to pediatric patients)

A 
Caretaker (mother, father, etc.)
Attends daycare
Attends school
Has brothers/sisters
Second-hand smoke exposure
Immunizations up to date

Scribe America Pre-Clinical Training (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions