Day 1 Flashcards
ED Flow
Chief Complaint (CC) > Physician Assessment: (H&P) > Objective Orders > Results and Medical Decision Making > Disposition
Vital Signs
HR: heart rate BP: blood pressure RR: respiratory rate T: temperature SaO2: oxygen saturation
Nurse Assessment
- Confirm chief complaint
- Review allergies
- Brief Past medical history
ED Flow: before Physician Orders
Walk-in/ EMS > Triage > Bed Placement > Nurse Assessment > H &P
ED Flow: After Physician Orders
Differential Dx >Physician Orders (Laboratory studies, Imaging Studies, Procedures, Medications) > Results& ED Course > Final Dx > Disposition
Differential Diagnosis (DDx)
Based on the H&P, the physician generates a list of things that may be causing the pt’s subjective symptoms. The doctor then places orders to r/o each differential.
Final Dx (Dx)
By using Medical Decision Making (MDM), the physician reviews specific results that can r/o DDx to reach the Dx.
Laboratory Studies Examples
blood work, microscopy, cultures, etc.
Imaging Studies Examples
x-ray, CT, US, EKG, etc.
Procedures Examples
Sutures, Joint reduction, splints, etc.
Results and ED Course
Patient re-evaluations and consults with specialists.
Disposition
Discharge home
Admit for further care
Transfer to another facility
Triage
Chief Complaint
Vital Signs
Level of Acuity (5 low-1 high)
H&P
Subjective: HPI & ROS
Past History: PMHx, PSHx,FHx, SHx
Objective: PE
Goals of a Scribe
- Perform rapid, accurate, and complete medicolegal documentation for emergency physicians.
- Increase the efficiency of the emergency physician.
What is a Scribe
An unlicensed person performing documentation and other non-clinical tasks under the direction of a licensed independent practitioner.
People in the ED
Charge Nurse Mid-level Practitioner ED Nurse Respiratory Therapist (RT) ED Tech Unit Secretary
Charge Nurse
manages the ED patient flow
Mid-Level Practioner
LNP or PA that works under the supervision of a physician to diagnose and treat patients.
ED Nurse
Records medical histories and symptoms monitors the patient starts IVs administers medications assists with procedures
Respiratory Therapist
Administers “breathing treatments”and assists with managing a patients airway.
ED Tech
Helps the nurse and assists with procedures
Unit Secretary
Places physician’s orders
answers phone calls
pages other specialists/doctors
organizes the patients paperwork
Subjective
Feeling
