Day 1: ED Flow: Part 1 Flashcards
Feeling vs. Fact
Subjective vs. Objective
The main reason for the patient’s ED visit
Chief Complaint
They physician’s thought process
Medical Decision Making
Patient’s feeling vs. Physican’s assessment
Pain vs. Tenderness
Normal, nothing of concern
Benign
The doctor’s judgement of discomfort
Distress
The state of having a fever, concerning for infection
Febrile
New onset, likely concerning
Acute
Long standing, not of direct concern
Chronic
An individuals normal state of being
Baseline
Listening with a stethoscope
Auscultation
The act of pressing on an area (by the doctor)
Palpation
Admitted to the hospital overnight
Inpatient
Seen and sent home the same day
Outpatient
Manages the ED patient flow
Charge Nurse
Nurse Practitioner (LNP) or Physician Assistant (PA) that works under the supervision of a physical to diagnose and treat patients
Mid-Level Provider
Records medical histories, symptoms, monitors the patient, starts IVs, administers medications, and assists with procedures
ED Nurse
Administers “breathing treatments” and assists with managing a patient’s airway
Respiratory Therapist (RT)
Helps the nurse and assists with procedures
ED Tech
Places physician’s orders, answers phone calls, pages other specialists/doctors, and organizes the patient’s paperwork
Unit Secretary
Documents the patient’s visit on behalf of the physician
Scribe
Emergency Department Flow Before Orders
- Walk In [Waiting Room]/ EMS [Ambulance Bay]
- Triage [chief complaint, vital signs, level of acuity]
- Bed Placement
- Nurse Assessment [confirm chief complaint, review allergies, brief past medical history]
- History and Physical (H & P)
[SUBJECTIVE: HPI/ROS]
[PAST HISTORY: PMHx/PSHx, FHx, SHx]
[OBJECTIVE: PE]
Emergency Department Flow After Orders
- Differential Diagnosis
- Physician Orders [laboratory studies, imaging studies, procedures, medications]
- Results & ED Course
- Final Diagnosis
- Disposition
Documentation Layout
- History of Present Illness (HPI)
- Review of Symptoms (ROS)
- Past History
- Physical Examination
- ED Course
- Disposition
Patient Complaint goes in
HPI or ROS
Past Diagnosis or Surgery
Past History
Physician’s Observation
Physical Exam
Objective Study
Results
Re-Evaluation
ED Course
Where they will go
Disposition
Vital Signs Obtained by the Nurse
Blood Pressure Heart Rate Respiratory Rate Temperature Oxygen Saturation
