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Scribing > Emergency Department Flow > Flashcards

Emergency Department Flow Flashcards

1
Q

Subjective vs. Objective

A

Feeling (pt) vs Fact (MD)

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2
Q

Chief Complaint

A

Main reason for pt visit

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3
Q

Medical Decision Making

A

The physician’s thought process

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4
Q

Pain vs. Tenderness

A

pt feeling vs. Physician’s assessment

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5
Q

Auscultation

A

Listening with a stethoscope

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6
Q

Palpation

A

Act of pressing on an area (by dr)

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7
Q

Scribes CAN NOT

A 
Touch pt
Write orders or prescriptions
Give verbal orders
Partake in any activity that may affect pt outcome
Sign/authenticate charts/records
Handle bodily fluids/specimens
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8
Q

Flow Overview

A

Check in/chief complaint -> Dr Assessment -> objective orders and results -> Medical decision making -> disposition

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9
Q

Documentation Template

A

HPI (sub) and ROS (sub) -> Past History -> PE (obj), ED Course (obj), and Disposition

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10
Q

HPI

A

History of Present Illness: Story and context of chief complaint

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11
Q

ROS

A

A head-to-toe list of positives and negatives

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12
Q

Past History

A

PMHx, PSHx, SHx, FHx

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13
Q

PE

A

Physical Examination: Physician’s objective findings

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14
Q

ED Course

A

Objective results: Labs, imaging, re-evals, consults, procedures

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15
Q

Disposition

A

Discharged home, admitted for further care, transfer to another facility, or death

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16
Q

Epic

A

Pres’s documentation system

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17
Q

I have high blood pressure

A

HTN: Hypertension

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18
Q

I have high cholesterol

A

HLD: Hyperlipidemia

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19
Q

I have thyroid problems

A

Usually Hypothyroidism, sometimes hyperthyroidism

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20
Q

I have diabetes

A

DM: Diabetes Mellitus

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21
Q

I only take pills for my diabetes

A

NIDDM

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22
Q

I take shots (insulin) for my diabetes

A

IDDM

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23
Q

I have heart disease

A

CAD

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24
Q

I’ve had a heart attack

A

MI and CAD

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25
Q

I’ve had heart failure

A

CHF

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26
Q

I have an irregular heart beat

A

A-Fib

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27
Q

I have a heart murmur

A

Heart murmur

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28
Q

I have episodes of racing heartbeats

A

SVT: Supraventricular Tachycardia

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29
Q

I have asthma

A

Asthma

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30
Q

I have emphysema/chronic bronchitis

A

COPD

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31
Q

I have a blood clot in my lung

A

PE

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32
Q

I’ve had pneumonia

A

PNA

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33
Q

I have acid reflux

A

GERD

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34
Q

I have an ulcer

A

Gastric Ulcer or Peptic Ulcer Disease

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35
Q

I have pancreatitis

A

Pancreatitis

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36
Q

I have hepatitis

A

Hepatitis A, B, or C

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37
Q

I have diverticulitis

A

Diverticulitis

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38
Q

I have Crohn’s/UC

A

Crohn’s Disease or Ulcerative Colitis

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39
Q

I have irritable bowels

A

IBS

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40
Q

I have a bladder infection

A

UTi

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41
Q

I have a kidney infection

A

Pyelonephritis (Pyelo)

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42
Q

I have kidney stones

A

Renal calculi

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43
Q

I’m on dialysis

A

CRF: Chronic renal failure
ESRD: End stage renal disease (dialysis, freq, last Tx)

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44
Q

I have an enlarged prostate

A

BPH: Benign Prostate Hypertrophy

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45
Q

G/P/A

A

Gravida: Total # times pregnant
Para: # live births
Abortion: # miscarriages or elective abortions

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46
Q

I’ve had a stroke

A

CVA: Cerebrovascular Accident

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47
Q

I’ve had a mini-stroke

A

TIA: Transient Ischemic Attack

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48
Q

I’ve had seizures

A

Seizure disorder/epilepsy

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49
Q

I’ve had a brain bleed

A

Hemmorrhagic CVA

50
Q

I’m bipolar

A

Bipolar disorder

51
Q

I’m schizophrenic

A

Schizophrenia

52
Q

I drink a lot

A

EtOH abuse/Alcoholism

53
Q

I do drugs

A

Substance Abuse

54
Q

I’ve had a blood clot in my leg

A

Lower Extremity DVT

55
Q

I have a bulge in my aorta

A

AAA: Abdominal Aortic Aneurysm

56
Q

I have bad blood flow to my legs

A

PVD: Peripheral Vascular Disease

57
Q

I have numbness in my legs

A

Peripheral Neuropathy

58
Q

I have Cancer

59
Q

My cancer has spread

A

With metastases

60
Q

I’m in chemo

A

Chemotherapy

61
Q

I’m in radiation

A

Radiation therapy

62
Q

They cut my cancer out

A

Status-post surgical resection

63
Q

My cancer is gone

A

In remission

64
Q

I have low back pain

A

Chronic low back pain

65
Q

I have a bulging/herniated disc

A

DDD: Degenerative Disc Disease

66
Q

I have arthritis

A

OA: Osteoarthritis (usually)
RA: Rheumatoid Arthritis

67
Q

I have joint pain (chronic)

A

DJD: Degenerative Joint Disease

68
Q

I have weak/fragile bones

A

Osteoperosis (usually)

69
Q

I’ve had my tonsils removed

A

Tonsillectomy

70
Q

I’ve had my adenoids removed

A

Adenoidectomy

71
Q

I have ear tubes

A

P.E.: Pressure Equalizer Tubes

72
Q

I’ve had a heart bypass

A

CABG -> PMHx CAD

73
Q

I’ve had stents inserted

A

Coronary stents -> PMHx CAD

74
Q

I have a heart cath

A

Cardiac catheterization

75
Q

I’ve had a balloon in my heart

A

Angioplasty -> PMHx CAD

76
Q

I’ve had valve surgery

A

Valve repair or replacement (bovine vs mechanical)

77
Q

I have a pacer

78
Q

I have a defibrillator

A

AICD: Automatic Implanted Cardiac Dibibrillator

79
Q

I’ve had surgery for Afib

A

Afib s/p cardiac ablation

80
Q

I’ve had my breast removed

A

Mastectomy

81
Q

I have a hole in my neck

A

Tracheostomy or trach

82
Q

I’ve had part of my lung removed

A

Partial lobectomy

83
Q

I’ve had my appendix removed

A

Appendectomy

84
Q

I’ve had my gallbladder removed

A

Cholecystectomy

85
Q

I’ve had a hernia repaired

A

Herniorrhalphy

86
Q

I’ve had part of my colon removed

A

Partial colectomy

87
Q

I have a bag to collect stool

A

Colostomy bag

88
Q

I’ve had my spleen removed

A

Splenectomy

89
Q

I’ve had my stomach stapled

A

Gastric bypass

90
Q

I’ve had exploratory surgery

A

Exploratory Laproscopy (ExLap)

91
Q

I’ve had my kidney removed

A

Nephrectomy

92
Q

I’ve had my uterus removed

A

Hysterectomy (partial vs total)

93
Q

I’ve had an ovary removed

A

Oophorectomy

94
Q

I’ve had my ovary and fallopian tubes removed

A

Salpingo-oophorectomy

95
Q

I’ve had my tubes tied

A

Tubal ligation (female) or Vasectomy (male)

96
Q

I’ve had a C-Section

A

Ceasarean section

97
Q

I’ve had my prostate removed

A

Prostatectomy (most often TURP: Trans-Urethral Removal of the Prostate)

98
Q

I’ve had a uterine product removed

A

D&C: Dilation and Curettage

99
Q

I’ve had my neck artery cleaned

A

Carotid Endarterectomy

100
Q

I’ve had brain surgery

A

Craniotomy (brain bleed vs CA)

101
Q

I have a shunt

A

VP Shunt (Ventriculoperitoneal)

102
Q

I have a dialysis fistula

A

AV (arteriovenous) fistula

103
Q

I have a dialysis graft

104
Q

I have a PICC line

A

PICC: Peripherally inserted central catheter

105
Q

I have a port

A

Port-a-cath or Medi-Port

106
Q

I have a clot filter (lower abdomen)

A

IVC (inferior vena cava) Filter

107
Q

I have a clot filter (leg)

A

Greenfield filter

108
Q

I’ve had my leg amputated

A

AKA: Above knee amputation
BKA: Below knee amputation

109
Q

I’ve had joint repaired

A

Arthroplasty

110
Q

I have metal plates/pin

111
Q

My neck is fused

A

Cervical spine fusion

112
Q

My back is fused

A

Lumbar spinal fusion

113
Q

I’ve had hip surgery

A

ORIF: Open Reduction with Internal Fixation

114
Q

Medical Allergy vs Adverse Reaction

A

Only a medication causing rash, itching, swelling, or difficulty breathing is a true allergy.

115
Q

FHx (Family History Topics)

A 
General: HTN, DM, CA 
Cardiac: MI/CAD less than 55 y/o
Pulmonary: PE, Asthma
GI: Crohn's, IBS
Neuro: CVA, Seizures, Aneurysm
Misc: Sickle cell, DVT
116
Q

Sx (Social History)

A

Tobacco, EtOH, Illicit Drugs, Occupation, Living circumstances

117
Q

Smoking Use

A 
Current (#ppd, #yrs)
Former (years quit)
Never 
Second-hand exposure
Chewing tobacco
118
Q

EtOH Use

A

Never
Occasionally/socially
Daily
Chronic (#dpd, type)

119
Q

Illicit Drug Use

A

Which drug
Route of administration
Date of last use

120
Q

Occupation

A

Employed
Unemployed
On disability
Retired

121
Q

Living Circumstances

A 
Lives alone
With family/friends
Nursing home/assisted living
Hospice
Homeless/shelter
122
Q

Pediatric Sx

A 
Caretaker
Attends daycare
Attends school
Has siblings
Second-hand smoke exposure
Immunizations UTD

Scribing (8 decks)

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