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Scribe Training > Course 5: Procedures > Flashcards

Course 5: Procedures Flashcards

1
Q

Procedure: Splint/Sling Application
Indication:
Key Documentation:

A

Extremity Injury

Distal CSMT intact

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2
Q

Procedure: Laceration Repair
Indication:
Key Documentation:

A

Laceration

Good closure and hemostasis

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3
Q

Procedure: I&D
Indication:
Key Documentation:

A

Abscess

Amount of type of purulence obtained

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4
Q

Procedure: Foreign Body Removal
Indication:
Key Documentation:

A

Foreign Body

Technique of removal, description of object removed

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5
Q

Procedure: Cerumen Disimpaction
Indication:
Key Documentation:

A

Ear complaints

Tools used and total time spent.

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6
Q

Procedure: Rectal Disimpaction
Indication:
Key Documentation:

A

Constipation or fecal impaction

Impaction resolved, symptoms improved

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7
Q

Procedure: Nail Trephination
Indication:
Key Documentation:

A

Subungual hematoma

Distal CSMT intact

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8
Q

Procedure: Epistaxis Management (cautery v packing)
Indication:
Key Documentation:

A

Nosebleed

Good hemostasis

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9
Q

Complaint: Joint Injury

Procedure?

A

Splint Application

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10
Q

Complaint: Laceration

Procedure?

A

Laceration Repair

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11
Q

Complaint: Abscess

Procedure?

A

Incision & Drainage

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12
Q

Complaint: Joint effusion

Procedure?

A

arthrocentesis

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13
Q

Complaint: Dislocation

Procedure?

A

joint reduction

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14
Q

Complaint: Headache, fever

Procedure?

A

LP

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15
Q

Complaint: Joint reduction

Procedure?

A

procedural sedation

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16
Q

Complaint: Respiratory failure

Procedure?

A

intubation

17
Q

Complaint: sepsis

Procedure?

A

central line placement

18
Q

Complaint: PTX

Procedure?

A

chest tube

19
Q

Complaint: abnormal heart rhythm

Procedure?

A

cardioversion

20
Q

Complaint: Cardiac arrest

Procedure?

21
Q

Complaint: COPD/CHF exacerbation

Procedure?

A

CPAP/BiPAP

22
Q

CCT

A

Critical Care Time:
Care provided to any pt that is at serious risk for deterioration that may lead to permanent bodily harm or health.

ask 1) does pt qualify for CCT? 2) How many minutes were provided? - need at least 30 min.

23
Q

Consultation Reasons (3)

A

1) ED doctor needs to admit a pt
2) ED doctor needs specialist advice
3) ED doctor calls pt PCP to inform them about their pt

24
Q

Format of Consultation Note

A
  1. Timestamp
  2. Name of provider being consulted
  3. Specialty
  4. What was discussed
25
Q

Re-evaluation Reasons (5)

A
  1. Pt about to be discharged.
  2. Pt about to be admitted.
  3. Pt needs abnormal vital signs re-checked.
  4. Physical exam finding needs to be re-checked
  5. Determine if a treatment was effective.

Scribe Training (23 decks)

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