Layout of a physician documentation template Flashcards
What is the template layout of scribe documentation?
(1) HPI (2) ROS (3) Past History (4) PE (5) ED Course (6) Disposition
What are the subjective complaint sections of the template?
(1) HPI (2) ROS
What are the objective evaluation sections of the template?
(1) PE (2) ED
HPI
The story and context of the Chief Complaint
ROS
Head-to-toe list of positives and negatives
Past History
PMHx, PSHx, SHx, RHx
PE
The physician’s objective findings
ED Course
Objective results (Labs, imaging, re-evals, Consults, Procedures)
Disposition
Discharge, Admit, Transfer
Where does a patient complaint go?
HPI or ROS
Where does a past diagnosis or surgery go?
Past History
Where does a physician’s observation go?
PE
Where does an objective study go?
Results/ED Course
Where does a re-evaluation go?
ED Course
Where does where the patient goes go?
Diagnosis and Disposition
