Day in the life of a scribe Flashcards
My proivder is my _______
Partner
Vital Signs
They give a quick look at a patient current health
What are the different types of vital signs?
- Heart Rate
- Respiratory rate
- Blood pressure
- Body Temp.
- Oxygen Saturation
What is the heart rate?
Its the pulse basically it measure the number of times a person heart beats per min (bpm)
What is the range for heart rate for an adult?
Between 60-100bpm
What does tachycardic mean?
Heart rate above 100 bpm
What does Bradycardic mean?
Heart rate is below 60bpm
What is the average range for the systolic number?
From 90 too 140
What is blood pressure?
Measures the pressure your heart pumps out blood
What does Hypertensive mean?
Means high blood pressure
What does Hypotensive mean?
Mean low blood pressure
Whats the average blood pressure for adults
120/80
120/80 whats the top number and the bottom number?
The top number is the systolic number and the bottm number is the diastolic number
What is the respiratory rate?
Measures the rate of a person breathing (breaths per min)
What is the average range for the distolic number?
From 60-90
What is body temp?
Measurement of your body’s ability to get rid of heat
What is the normal body temp?
98.6℉
A fever is anything from what?
From 100.4℉ and up
What is oxygen saturation?
Measures how much of our blood is oxygen
What is the normal range for oxygen saturation?
95% to 100%
What is the normal heart rate for babies ?
Between 120 - 160bpm
When is a baby heart rate tachycardic?
When its above 160 bpm
When is a baby heart rate bradycardic?
When its below 120bpm
Whats the normal respiratory rate for adults?
12-20 breaths per min
When is an adult tachypenic?
When there repsiratory rat eis above 20
When is an adult bradypnea?
When their respiatory rate is below 12
What is the normal respiratory for babies?
30-50 breaths per min
When is a baby Tachypneic?
When its above 50
When is a baby bradypnea?
When its below 30
What the normal blood pressure range for adults?
90/ 60 - 140/90
When is an adult hypertensive?
When their blood pressure is above 140/90
When is an adult hypotensive?
When its below 90/60
For baby blood pressure what number do we look at?
The systolic number (top number)
Whats the normal systolic (blood pressure) for babies?
50- 120
When is a baby hypertensive?
When blood pressure is 120
When is a baby Hypotensive?
When blood pressure is below 50
Whats the normal body temp for babies and adults?
98.6℉
Afebrile means what?
Means you dont have a fever (Body temp 98.6℉)
What does febrile mean?
Means that you have a fever (Body temp higher than 100.4 ℉)
What does hypothermic mean?
Means you have a low body temp (less than 98.6℉)
Whats the normal oxygen saturation level for adults & babies?
95% - 100%
Whats the term for low oxygen saturation that is less than 95%?
Hypoxic
What are the different type of healthcare settings?
- Outpatient office
- Emergency department
- impatient - hospitalist
- Urgent Care
What is Urgent Care?
Its like a mini ER that used for something that cant wait for a appointment but its not life or death
What is an emergency?
When someone is unresponsive or any organs has failed showing life threatening illness
Who is part of the team?
- The provide
- Advance pratice provider
- Nurses or medical assistants
- Technicans
- Scribe
In medical termology what does the prefix represent and what does the suffix represent?
Prefix - refers to an organ & suffix - refers to whats wrongs (Ex Pancreaitis - means inflammation in the pancreas)
What are the common prefixes?
- Tachy - means fast
- Brady - means slow
- Hyper - means too much/ overactive
- Hypo - means too little/ underactive
What are the common suffixes?
- itis - means inflammation or infection
- osis - disease of something
- ectomy - surgical removal of something
- otomy - hole or opening
What are the two parts a medical chart is broken into?
- Subjective
- Objective
What is subjective?
Its what the pateint tells us
What is objective?
Its what the doctor tells us
What is pain considered and what is tenderness consider as?
Pain is consider as subjective and tenderness is consider as objective
What are the different types of histories?
- Medical History
- Family History
- Social History
What in the medical history?
It includes:
1. Any prior medical problems like chronic problems
- Past surgeries
- Allergies to medications
What are the true systoms for an allergic reation?
- Rash
- Shortness of breath
- Ititchiness & weezing
Whats in the family history?
Its history that is only directly related to family members with a medical problem & includes all of the same medical histories ( direct family is like mom dad, etc & the younger someone is with an illness its mostly family relates)
What is in the social history?
Its a history that notes the dialy habits of a person life which would include:
- Alcohol use
- Smoking or tobacco use
- Ocupation
- Living Status
What is an adverse reaction?
Its a side affect from taking a medication ( Ex. having dry mouth after taking a pill)
