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ScribeAmerica ED Classroom Training > Course 1: Welcome and Patient Health History > Flashcards

Course 1: Welcome and Patient Health History Flashcards

1
Q

Scribe Role

A

Present during all data gathering and chart documentation; Responsibility is to update the Electronic Health Record (EHR) for the provider

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2
Q

Scribes CAN…

A

Document the history, physical exam, results procedures, and consults; Access and document laboratory results and radiology findings; Access and display X-rays for the physician to review; Locate and obtain medical history, previous charts, and past results; Record physician interpretations of X-rays and EKG/ECGs

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3
Q

Scribes CANNOT…

A

Touch patients; Write orders or prescriptions; Give verbal orders; Sign or authenticate any chart or record (on behalf of the provider); Handle bodily fluids or specimens

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4
Q

Who do scribes work with?

A

Mid-level provider, Charge nurse, Nurse, Tech, Respiratory therapist (RT), Unit secretary

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5
Q

Mid-Level Provider

A

Licensed nurse practitioner (NP) or physician assistant (PA)

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6
Q

Charge Nurse

A

Manages ED patient flow

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7
Q

Nurse

A

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

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8
Q

Tech

A

Helps the nurse/provider and assists with procedures

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9
Q

Respiratory Therapist (RT)

A

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

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10
Q

Unit Secretary

A

Answers phone calls, pages other specialists/doctors, and organizes the patient’s paperwork

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11
Q

ED Flow

A
  1. Check-in and triage
  2. History and physical
  3. Differential diagnosis
  4. Orders and treatment
  5. Medical decision making
  6. Disposition
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12
Q

Triage

A

Chief complaint (CC), vital signs, level of acuity

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13
Q

Vital signs

A
  1. Heart rate/HR (bpm)
  2. Blood pressure/BP (mm Hg)
  3. Respiratory rate/RR
  4. Temperature/T (°F/°C)
  5. Oxygen saturation/SaO2 (%)
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14
Q

Level of Acuity

A

Measures urgency of a case; 1 (high) to 5 (low)

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15
Q

Nurse Assessment

A

Confirm chief complaint; brief past medical history; current medications; allergies

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16
Q

Physician: History and Physical (H&P)

A

History of present illness (HPI); Review of systems (ROS); Past history (medical, surgical, family, social); Physical exam (PE)

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17
Q

Physician: Differential Diagnoses (DDx)

A

Based on the history and physical, the physician generates a list of possible diagnoses and then places orders to rule out each diagnosis

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18
Q

Physician: Orders and Treatment

A

Laboratory studies, imaging studies, procedures, medications

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19
Q

Laboratory studies

A

Blood work, urinalysis, microscopy, cultures

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20
Q

Imaging studies

A

EKG, X-ray, CT, ultrasound

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21
Q

Procedures

A

Sutures, joint reduction, splints

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22
Q

Medications

A

Antiemetics, analgesics, vasodilators, diuretics, antibiotics

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23
Q

Physician: Medical Decision Making (MDM)

A

Physician formulates a diagnosis or treatment plan by considering the history and physical, past medical record, laboratory results, radiology results, and consults with specialists

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24
Q

Physician: Disposition

A

Discharged to home, discharged to nursing facility, admitted, transferred, left against medical advice (AMA), expired

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25
Q

Medical chart layout

A
  1. History of present illness (HPI)
  2. Review of systems (ROS)
  3. Past history
  4. Physical examination (PE)
  5. ED course
  6. Diagnosis and disposition
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26
Q

Patient says high blood pressure

A

Hypertension (HTN)

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27
Q

Patient says high cholesterol

A

Hyperlipidemia (HLD)

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28
Q

Patient says diabetes

A

Diabetes Mellitus (DM)

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29
Q

Patient says “I only take pills for my diabetes”

A

Non-Insulin Dependent Diabetes Mellitus (NIDDM)

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30
Q

Patient says “I take shots for my diabetes”

A

Insulin Dependent Diabetes Mellitus (IDDM)

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31
Q

Patient says heart disease

A

Coronary Artery Disease (CAD)

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32
Q

Patient says heart attack

A

Myocardial Infarction (MI) and Coronary Artery Disease (CAD)

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33
Q

Patient says heart failure

A

Congestive Heart Failure (CHF)

34
Q

Patient says irregular heartbeat

A

Arrhythmia

35
Q

Patient says asthma

A

Asthma

36
Q

Patient says emphysema or chronic bronchitis

A

Chronic Obstructive Pulmonary Disease (COPD)

37
Q

Patient says blood clot in lung

A

Pulmonary Embolism (PE)

38
Q

Patient says pneumonia

A

Pneumonia (PNA)

39
Q

Patient says reflux

A

Gastroesophageal Reflux Disease (GERD)

40
Q

Patient says ulcers

A

Gastric Ulcer or Peptic Ulcer Disease (PUD)

41
Q

Patient says pancreatitis

A

Pancreatitis

42
Q

Patient says hepatitis

A

Hepatitis

43
Q

Patient says irritable bowel

A

Irritable Bowel Syndrome (IBS)

44
Q

Patient says bladder infection

A

Urinary Tract Infection (UTI)

45
Q

Patient says kidney infection

A

Pyelonephritis

46
Q

Patient says kidney stones

A

Renal Calculi

47
Q

Patient says “I’m on dialysis”

A

Chronic Kidney Disease (CKD) on dialysis

48
Q

Patient says enlarged prostate

A

Benign Prostatic Hyperplasia (BPH)

49
Q

GPA

A

Gravida: Number of total pregnancies

Para: Number of successful pregnancies

Abortus: Number of unsuccessful pregnancies

50
Q

Patient says stroke

A

Cerebrovascular Accident (CVA)

51
Q

Patient says blockage in the brain

A

Ischemic CVA

52
Q

Patient says brain bleed

A

Hemorrhagic CVA

53
Q

Patient says mini stroke

A

Transient Ischemic Attack (TIA)

54
Q

Patient says blood clot in my leg

A

Deep Vein Thrombosis (DVT)

55
Q

Patient says bulge in my aorta

A

Aortic Aneurysm

56
Q

Patient says bad blood flow to my legs

A

Peripheral Vascular Disease (PVD)

57
Q

Patient says tonsils removed

A

Tonsillectomy

58
Q

Patient says adenoids removed

A

Adenoidectomy

59
Q

Patient says ear tubes

A

Pressure Equalizer (PE) tubes

60
Q

Patient says balloon in my heart

A

Angioplasty (PMHx of CAD)

61
Q

Patient says stents in my heart

A

Coronary stents (PMHx of CAD)

62
Q

Patient says heart bypass

A

Coronary Artery Bypass Graft (CABG) [PMHx of CAD]

63
Q

Patient says breast removal

A

Mastectomy

64
Q

Patient says part of my lung removed

A

Partial lobectomy

65
Q

Patient says appendix removed

A

Appendectomy

66
Q

Patient says gallbladder removed

A

Cholecystectomy

67
Q

Patient says part of my colon removed

A

Partial colectomy

68
Q

Patient says spleen removed

A

Splenectomy

69
Q

Patient says kidney removed

A

Nephrectomy

70
Q

Patient says uterus removed

A

Hysterectomy

71
Q

Patient says ovary removed

A

Oophorectomy

72
Q

Patient says ovary removed and fallopian tube removed

A

Salpingo-oophorectomy

73
Q

Patient says prostate removed

A

Prostatectomy

74
Q

Family History

A

Includes any medical condition present in the patient’s blood relatives; age of onset less than 55 years old is important for genetic risk factors

75
Q

Social History

A

Tobacco Use/Vaping; Alcohol use; Drug use; Occupational circumstances; Living circumstances

76
Q

Tobacco Use/Vaping

A

Packs Per Day (PPD)

77
Q

Drug Use

A

What substance?; Route of administration; Date of last use/how often?

78
Q

Occupation

A

Manual labor; Stress; Night shifts; etc.

79
Q

Living Circumstances

A

Live alone; Live with family/friends; Nursing home/assisted living; Hospice; Homeless

80
Q

True allergy

A

Rash, itching, swelling, difficulty breathing

ScribeAmerica ED Classroom Training (5 decks)

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