SCRIBE FINAL Flashcards
The critical care time is between:
30-74 min (1st level)
75-105 (2nd level)
How long is the core measure for smoking?
3-10 min
How long is the core measure for alcohol?
15-30 min
Are all ortho joint reductions performed under general anathesia: T or F
False
Name 5 elements of the HPI
Onset Location Duration Character Aggravating factors Radiation Timing Severity
List 3 acceptable caveats
Intoxicated, dementia, intubated
Name 5 organ systems in the physical exam section of the chart.
Head, eyes, ears, nose, throat, neck
What is Dr. Azmoon’s specialty?
Cardiology
What is Dr. Channell’s specialty?
Gynecology
Name a physician that works in surgery?
Dr.Garg
What is the brand name for the medication Odansetron?
Zofran
Brand name for Metronidazole
Flagyl
Brand name for hydrocodone
Norco
Brand name for Hydromorphone
Dilaudid
Brand name for cerfriaxone
Rocephin
Define the term laceration
A cut
Why would a patient receive antibiotics during an emergency department?
To treat bacterial infection
What is meant by the term mid level provider?
Nurse practitioner and physician assistant
What are three medications that signify the pt is likely receiving critical care?
TPA, narcan, NTG drip
What should be included for every procedure?
Date, time, who performed the procedure.
Where do you document associated symptoms?
In the free text narrative and the drop down boxes
Is accurate chronology important in an HPI
Yes
How many elements need to be included in the HPI focused chart?
4 elements as well as chief complaint
True or false: lacerations are billed based on length
True
Why would our hospital receive a trauma patient?
Because we’re the closest hospital
What template do you use for the review of systems (ROS)?
…ROSQUICK
‘Pedsexam ‘Fullneuro ‘Iimitedexam ‘Universal Are all templates that would be documented under what?
Physical exam
What do you document under core measure?
Dr counsels pt, gave pt resources, and included it in DCI
Paced EKG’s do not include what?
ST segments, T-wave abnormalities, axis, or conduction
Why do we use “EKG” and not “ECG”
Medical tradition is important
Where in the EKG do you include BPM?
After normal sinus
What are the billing requirements for EKG?
- Interpreter
- 3 positive-negative findings
- Rate/ rhythm
Murphy’s sign
cholecystitis
McBurney’s sign
acute appendicitis
Brudzinski’s Sign
meningitis
kernig’s sign
meningitis/ subarachnoid hemorrhage
6 reasons for reevaluation notes
- provider greets patient
- Vitals signs rechecked
- exam findings need to be rechecked
- determine if particular treatment is effective
- admission
- discharge
3 procedures that include the risk/ benefit
blood transfusion, lumbar puncture, sedation
LFT
liver function
BUN
blood, urea, nitrogen
kidney function
BUN + creatine+ eGFR