Documentation Ch. 3

Question 1

The 7 sections of the medical chart

Answer 1

HPI

Historical: past, medical, fam, and social

ROS

Physical exam

ED course (procedures, labs, x-rays, rechecks, response to treatment, etc.)

Diagnosis

Disposition: stable (discharged), guarded (admitted to floor), critical care (admitted to ICU), expired

Question 2

7 areas of the CC

Answer 2

L: Location (ex: ankle)

Q: Quality (ex: burning, like a knife, just hurts, etc.)

S: Severity (ex: scale 1-10, degree of fever)

T: Timing/Duration (ex: improving, worsening, intermittent, constant, etc.)

Context: risk factors, previous treatment

P: Modifying Factors: exacerbating factors (make it worse), and mitigating factors (make it better)

Associated signs and symptoms

Question 3

The areas that always need to be included: OPQRST

Answer 3

O- onset
P- provocation 
Q- quality
R- radiation 
S- severity
T- time

Question 4

ED Paragraph 1

Answer 4

Patient was seen and examined

What monitors/ precautions I placed on (ex: cardiac monitor, pulse oximetry, oxygen, seizure pads, arrived on c-collar or backboard, restraints

Meds given (ex: IV established, meds given w/ route, fluids given: bolus or infusion

Labs drawn (include if blood cultures taken)

EKG Ordered

Imaging Orders (ex: X-ray, CT, Ultrasound)

Question 5

ED Paragraph 2

Answer 5

Results***

The EKG showed…
Lab results
Imaging results

Updates with time stamps
      Re-evaluations
      Convos w/ doc or fam
      New meds
      Change in status/ vitals

Question 6

ED Paragraph 3

Answer 6

Disposition: update on condition

Patient discharge: prescriptions, follow-ups, return precautions, patient agreeable with plan

Patient was admitted: to what doctor in regards to what CC, any consults, any further orders, “admission order was written”, patient/ fam agreeable with plan