SCRIBE FINAL Flashcards

1
Q

The critical care time is between:

A

30-74 min (1st level)

75-105 (2nd level)

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2
Q

How long is the core measure for smoking?

A

3-10 min

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3
Q

How long is the core measure for alcohol?

A

15-30 min

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4
Q

Are all ortho joint reductions performed under general anathesia: T or F

A

False

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5
Q

Name 5 elements of the HPI

A
Onset 
Location
Duration 
Character 
Aggravating factors 
Radiation 
Timing 
Severity
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6
Q

List 3 acceptable caveats

A

Intoxicated, dementia, intubated

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7
Q

Name 5 organ systems in the physical exam section of the chart.

A

Head, eyes, ears, nose, throat, neck

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8
Q

What is Dr. Azmoon’s specialty?

A

Cardiology

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9
Q

What is Dr. Channell’s specialty?

A

Gynecology

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10
Q

Name a physician that works in surgery?

A

Dr.Garg

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11
Q

What is the brand name for the medication Odansetron?

A

Zofran

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12
Q

Brand name for Metronidazole

A

Flagyl

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13
Q

Brand name for hydrocodone

A

Norco

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14
Q

Brand name for Hydromorphone

A

Dilaudid

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15
Q

Brand name for cerfriaxone

A

Rocephin

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16
Q

Define the term laceration

A

A cut

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17
Q

Why would a patient receive antibiotics during an emergency department?

A

To treat bacterial infection

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18
Q

What is meant by the term mid level provider?

A

Nurse practitioner and physician assistant

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19
Q

What are three medications that signify the pt is likely receiving critical care?

A

TPA, narcan, NTG drip

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20
Q

What should be included for every procedure?

A

Date, time, who performed the procedure.

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21
Q

Where do you document associated symptoms?

A

In the free text narrative and the drop down boxes

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22
Q

Is accurate chronology important in an HPI

A

Yes

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23
Q

How many elements need to be included in the HPI focused chart?

A

4 elements as well as chief complaint

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24
Q

True or false: lacerations are billed based on length

A

True

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25
Q

Why would our hospital receive a trauma patient?

A

Because we’re the closest hospital

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26
Q

What template do you use for the review of systems (ROS)?

A

…ROSQUICK

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27
Q
‘Pedsexam
‘Fullneuro
‘Iimitedexam
‘Universal 
Are all templates that would be documented under what?
A

Physical exam

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28
Q

What do you document under core measure?

A

Dr counsels pt, gave pt resources, and included it in DCI

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29
Q

Paced EKG’s do not include what?

A

ST segments, T-wave abnormalities, axis, or conduction

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30
Q

Why do we use “EKG” and not “ECG”

A

Medical tradition is important

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31
Q

Where in the EKG do you include BPM?

A

After normal sinus

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32
Q

What are the billing requirements for EKG?

A
  1. Interpreter
  2. 3 positive-negative findings
  3. Rate/ rhythm
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33
Q

Murphy’s sign

A

cholecystitis

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34
Q

McBurney’s sign

A

acute appendicitis

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35
Q

Brudzinski’s Sign

A

meningitis

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36
Q

kernig’s sign

A

meningitis/ subarachnoid hemorrhage

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37
Q

6 reasons for reevaluation notes

A
  1. provider greets patient
  2. Vitals signs rechecked
  3. exam findings need to be rechecked
  4. determine if particular treatment is effective
  5. admission
  6. discharge
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38
Q

3 procedures that include the risk/ benefit

A

blood transfusion, lumbar puncture, sedation

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39
Q

LFT

A

liver function

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40
Q

BUN

A

blood, urea, nitrogen

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41
Q

kidney function

A

BUN + creatine+ eGFR

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42
Q

BNP

A

B type natriuretic peptide

43
Q

coags

A

PT/INR/PTT

44
Q

CBC

A

complete blood count

45
Q

CMP

A

complete metabolic panel

46
Q

BMP

A

basic metabolic panel

47
Q

ABG

A

arterial blood gas

48
Q

UA

A

urinalysis

49
Q

when to ask about Critical Care patients?

A

after seeing critical patients
midway through shift
end of shift

50
Q

define critical care patient

A

in danger of losing life or limb

51
Q

how to tell if provider is doing a limited exam

A

not using stethoscope

52
Q

Sclera

A

White of the eye

53
Q

Conjunctiva

A

Mucous membrane covering the skin of the eye

54
Q

What does NML stand for?

A

Normal

55
Q

What is Ecchymosis

A

Bruising

56
Q

What is ortho joint reduction?

A

Reducing dislocation

57
Q

Ortho FX care:

A

Fixing long bone

58
Q

In what three words describe a patient status?

A

Improved, expired, stabilized

59
Q

Name 2 doctors in pediatrics:

A

Dagher

Jain

60
Q

Name 2 doctors in cardiology:

A

Choudhary

Azmoon

61
Q

Name 2 doctors in family medicine:

A

Barag

Gabrillo

62
Q

Name 1 doctor in neurology:

A

Altamimi

63
Q

Worth 2 points in medical decision making?

A
  • Independent interpretation of radiology results

- Review and summary of old records

64
Q

When is the only time you don’t write the date “5 days ago” and write “15 January 2018” instead?

A

Lab results or in comparison to an old EKG

65
Q

2 ways to test cerebellar function?

A

Finger to nose

Heel to shin

66
Q

4 possible causes of facial droop?

A
  1. CVA
  2. Bell’s Palsy
  3. Complex migraines
  4. Todd’s paralysis
67
Q

How many components do you need for PMSFH?

A

2 components 1 finding per component per system

68
Q

HPI components:

A

OLD CARTS, primary doctor, and associate symptoms

69
Q

How many points needed for comprehensive billing in a medical decision making?

A

4 points

70
Q

How many systems needed for comprehensive billing in ROS?

A

10 systems

71
Q

2 types of aphasia:

A
  1. receptive: word salad

2. expressive: know what they’re saying but can’t put it into words

72
Q

Where in the EKG section of the chart do you document the following?

LBBB

A

Conduction

73
Q

Define antiemetic:

A

Medication used to treat nausea and vomiting

74
Q

Define analgesic:

A

Medications used to treat pain

75
Q

What is normal heart rate?

A

60-100 BPM

76
Q

What is bradycardic?

A

Heart rate equal to or less than 59 BPM

77
Q

What is tachycardic?

A

Heart rate equal to or greater than 101 BPM

78
Q

What template do you use for HPI?

A

`gentem

79
Q

Emergency labs: (9)

A
CBC w/ differential
BMP
BNP
CMP
Troponin 
uDip 
COAGS
ABG
D-Dimer
80
Q

Unit of EKG?

A

BPM

81
Q

Name 3 core measures:

A
  1. Council the pt. in the room
  2. Provide printed resources at time of DC
  3. Print alcohol cessation instruction in DCI
82
Q

List 3 common CC diagnoses:

A

CPR (cardiac arrest)
AFIB
MI

83
Q

Which diagnoses would CT scans be used for? (4)

A

Appendice
Masses
Tumor
TAA

84
Q

What diagnosis would LP be used for?

A

Meningitis

85
Q

Specialist don’t admit, they only consult except for which exceptions:

A

OBGYN or surgery

86
Q

Colle’s fracture:

A

Breaking hands by falling forwards

87
Q

List 2 analgesics:

A

Ketorolac

Acetaminophen (safest)

88
Q

List 2 antibiotics:

A

Ceftriaxone

Ciprofloxacin

89
Q

List 2 antiemetics:

A

Ondansetron (most used)

Promethazine

90
Q

How many elements need to be included in the HPI for a comprehensive/level 5 chart?

A

4 elements = chief complaint

91
Q

Where in the EKG section of the chart do you document the following?

Multifocal PVC’s

A

Arrhythmia, rhythm

92
Q

Where in the EKG section of the chart do you document the following?

Right superior axis deviation

A

Axis

93
Q

Where in the EKG section of the chart do you document the following?

Low voltage QRS

A

Conduction

94
Q

Where in the EKG section of the chart do you document the following?

T wave abnormality, consider lateral ischemia

A

T-wave

95
Q

Where in the EKG section of the chart do you document the following?

Early repolarization

A

Rhythm

96
Q

Where in the EKG section of the chart do you document the following?

Atrial flutter

A

Dysrhythmia

97
Q

NSAID:

A

Nonsteroidal antiinflammatory drug

98
Q

PNA

A

Pneumonia

99
Q

NTG

A

Nitroglycerin

100
Q

TIA

A

Transient ischemic attack

101
Q

PVC

A

Premature ventricular contraction

102
Q

TAA

A

Thoracic aortic aneurism

103
Q

What are the 3 requirements for critical care time?

A

Critical illness
Critical Intervention
Critical Time

104
Q

3 common critical care procedures:

A

BIPAP/CPAP
Central line
Pacemaker placed