ED 1

Question 1

Chief Complaint

Answer 1

The main reason for patients ED visit

Question 2

EMR/EHR

Answer 2

Electronic medical record / electronic health record

Question 3

Subjective

Answer 3

feeling

Question 4

Objective

Question 5

Pain

Question 6

Tenderness

Question 7

Acute

Question 8

Chronic

Question 9

Triage

Question 9

History & Physical

Question 10

Differential Diagnosis

Question 11

Orders & Treatment

Question 12

Medical Decision Making

Question 13

Disposition

Answer 13

Discharged to home / nursing home /

Question 14

Medical Chart

Answer 14

History of present illness *written in complete sentances.
Review of systems * +/-
History
Vitals
Physical exam
Orders/Results
Course

Question 15

Heart Disease

Answer 15

Coronary Artery Disease

Question 16

Heart Attack

Answer 16

Myocardial Infraction and CAD

Question 17

Heart Failure

Answer 17

Congestive Heart Failure

Question 18

Irregular Heartbeat

Answer 18

Arrhythmia

Question 19

High Blood Presssure

Answer 19

Hypertension

Question 20

High Cholesterol

Answer 20

Hyperlipidemia

Question 21

Diabetes

Answer 21

Diabetes Mellitus

Question 22

“I only take pills for my diabetes”

Answer 22

Non-INsulin Dependant Diabetes Mellitus

Question 23

“I take shots (insulin) for my diabetes”

Answer 23

Insulin Dependant Diabetes Mellitus

Question 24

Asthma

Answer 24

Asthma

Question 25

Emphysema or Chronic Bronchitis

Answer 25

Chronic Obstructive Pulmonary Disease

Question 26

Blood clot in lung

Answer 26

Pulmonary Embolism

Question 27

Pneumonia

Answer 27

Pneumonia (PNA)

Question 28

Reflux

Answer 28

Gastroesophageal Reflux Disease (GERD)

Question 29

Ulcers

Answer 29

Gastric Ulcer or Peptic Ulcer Disease (PUD)

Question 30

Pancreatitis

Answer 30

Pancreatitis

Question 31

Hepatitis

Answer 31

Hepatitis

Question 32

Irritable Bowel

Answer 32

Irritable Bowel Syndrom (IBS)

Question 33

Bladder Infection

Answer 33

Urinary Tract Infection (UTI)

Question 34

Kidney Infection

Answer 34

Pyelonephritis

Question 35

Kidney Stones

Answer 35

Renal Calculi

Question 36

"I'm on dialysis"

Answer 36

Chronic Kidney Disease (CDK) on dialysis

Question 37

Enlarged Prostate

Answer 37

Begnin Prostatic Hyperplaysia (BPH)

Question 38

Gravida

Answer 38

Total # of times patient has been pregnant

Question 39

Para

Answer 39

Number of pregnancies that resulted in a live birth

Question 40

Abortus

Answer 40

Number of miscarriages or elective abortions

Question 41

Stroke

Answer 41

Cerebrovascular Accident (CVA)

Question 42

Blockage in the brain

Answer 42

Ischemic CVA

Question 43

Brain Bleed

Answer 43

Hemorragic CVA

Question 44

"Blood clot in my leg"

Question 45

"Mini Stroke"

Question 46

"Bulge in my aorta"

Question 47

"Bad blood flow in my legs"

Question 48

Tonsils removed

Question 49

Adenoids Removed

Question 50

Ear tubes

Question 51

"Balloon in my heart"

Question 52

"Stents in my heart"

Question 53

Heart bypass

Question 54

Breast Removal

Question 55

Appendix removed

Question 56

Partial lung removal

Question 57

Gallbladder removed

Question 58

Partial colon removal

Question 59

Sleen removed

Question 61

Kidney removed

Question 62

Uterus Removed

Question 63

Ovary removed

Question 64

Ovary and fallopian tube removed

Question 65

Prostate removed

Question 66

Family Hx

Answer 66

Any medical condition present in paitents blood relatives.

Question 67

Social Hx

Answer 67

Tabacco use / vapping

Question 68

Alcohol use

Question 69

Drug use

Question 70

Occupation

Question 71

Living circumstances

Question 72

Medications & Allergies

Question 73

Key things to doccument

Answer 73

Reviewing external records Documenting independant historians Capturing chronic illnesses