Week 1 - Patient Health History Flashcards
Give some examples of what is out of scope for scribes?
Touch patients
Write orders or prescriptions
Give verbal orders
Sign or authenticate any chart or record
Handle bodily fluids or specimens
What do you call the main reason for the patient’s emergency visit?
Chief complaint
EMR/EHR
Electronic medical record/electronic health record
Difference between subjective and objective
Feelings from the patient
Factual findings from the provider
Difference between pain and tenderness
Patient’s feeling of discomfort
Doctor’s finding of reproducible pain
Difference between acute and chronic
New onset, likely concerning
Long-standing, not of direct concern
What is the emergency department flow?
Check In & Triage
History & Physical
Differential Diagnosis
Orders & Treatment
Medical Decision Making
Disposition
What are the main vital signs and their abbreviations?
(HR) Heart rate (bpm)
(BP) Blood pressure (mmHg)
(RR) Respiratory rate
T: Temperature (C or F)
SaO2: Oxygen Saturation (%)
Level of Acuity: 1 (High) to 5 (Low)
When does the scribes documentation begin?
The HPI and ROS (after the nurse assessment)
History of Present Illness and Review of Systems
What will the physician do with the H&P?
These leads to differential diagnoses (DDx)
The physician generaties a list of things that MAY be causing the patient’s subjective symptoms.
Then the doctor places orders to “rule out” each differential.
What are types of lab studies the physician may order?
Blood work, urinalysis, microscopy, cultures
What are types of imaging studies the physician may order?
EKG/ECG, X-Ray, CT, Ultrasound
What are types of procedures the physician may order?
Sutures, joint reduction, splints
What are types of medications the physican may order?
Antiemetics, analgesics, vasodilators, diuretics, antibiotics.
Antiemetics are used to prevent or treat nausea and vomitting.
Analgesics are painkillers and pain medications aimed at redcucing pain.
Vasodilators are meds that open or dilate blood vessels especially in high blood pressure events.
Diuretics help rid body of water and sodium. This increase salt production of the liver, removing excess water from the blood, decreasing the amount of fluid flowing through your veins and arteries which reduces blood pressure.
Antibiotics are medicines that fight bacterial infections in people and animals.
What comes after the orders and treatment for the emergency department flow for a specific patient?
What comes after this?
The medical decision making (MDM) consists of the diagnosis or treatment plan. (discharged, admitted, trasnferred, left AMA (against medical advice), expired)
The disposition of the patient comes after the MDM.
What do the subjective complaints consist of?
What does the objective evaluation consist of?
HPI/ROS
Physical exam/Orders and Treatment
PMHx The Most Common
high blood pressure
Hypertension (HTN)
PMHx The Most Common
high cholesterol
Hyperlipidemia (HLD)
PMHx The Most Common
Diabetes
Diabetes Mellitus (DM)
PMHx The Most Common
I only take pills for my diabetes
Non-insulin dependent diabetes mellitus (NIDDM)
PMHx The Most Common
I take shots (insulin) for my diabetes
Insulin dependent diabetes mellitus (IDDM)
PMHx Cardivascular
heart disease
Coronary Artery Disease (CAD)
PMHx Cardivascular
heart attack
Myocardial Infarction (MI) and CAD
PMHx Cardivascular
heart failure
Congestive Heart Failure (CHF)
PMHx Cardivascular
irregular heartbeat
Arrhythmia
PMHx Pulmonary
asthma
Asthma
PMHx Pulmonary
Emphysema or chronic bronchitis
Chronic Obstructive Pulmonary Disease (COPD)
PMHx Pulmonary
Blood clot in lung
Pulmonary Embolism (PE)
PMHx Pulmonary
Pneumonia
Pneumonia (PNA)
PMHx Gastrointestinal
Reflux
Gastroesophageal Reflux Disease (GERD)
PMHx Gastrointestinal
Ulcers
Gastric Ulcer or Peptic Ulcer Disease (PUD)
PMHx Gastrointestinal
Pancreatitis
Pancreatitis
PMHx Gastrointestinal
Hepatitis
Hepatitis
PMHx Gastrointestinal
Irritable bowel
Irritable Bowel Syndrome (IBS)
PMHx Genitourinary
Bladder infection
Urinary Tract Infection (UTI)
PMHx Genitourinary
Kidney infection
Pyelonephritis
PMHx Genitourinary
Kidney stones
Renal Calculi
PMHx Genitourinary
I’m on dialysis
Chronic Kidney Disease (CKD) on dialysis
PMHx Genitourinary
enlarged prostate
Benign Prostatic Hyperplasia (BPH)
PMHx Gynecological
What is the convention for documentating past pregnancies, births, and abortions that you must be familiar with?
This is considered a pertinent part of PMHx for any female patient.
The convention is known as G: P: A:
- Gravida “G” is the total number of times the patient has been pregnant
- Para “P” is the number of pregnancies that resulted in viable births
- Abortus “A” is the total number of miscarriages or elective abortions
PMHx Vascular
Stroke
Blockage in the Brain
Brain bleed
Cerebrovascular Accident (CVA)
Ischemic CVA
Hemorrhagic CVA
PMHx Vascular
“Mini stroke”
Blood clot in my leg
“Bulge in my aorta”
“Bad blood flow in my legs”
Transcient Ischemic Attack (TIA)
Deep vein thrombosis (DVT)
Aortic Aneurysm
Peripheral Vascular Disease (PVD)
What do these abbreviations mean?
History information is not always relevant to the chief complaint, so we place all history infor in the PHx which includes PMHx, PSHx, SHx, and FHx
PHx = Past History sections
PMHx = Past Medical History
PSHx = Past Surgical History
SHx = Social History
PHx = Family History
What does the following mean?
itis
osis
ectomy
nephr
chole
mast
hepa
itis is inflammation
osis is disease
ectomy is surgical removal
nephr is kidneys/renal (renal relates to the FUNCTION of kidneys)
chole is gallbladder
mast is breasts
hepa is liver
Translate the following laymen speak of past surgical history:
Tonsils removed
Adenoids removed
Ear Tubes
Tonsillectomy
Adenoidectomy
Pressure Equalizer (P.E.) Tubes
Translate the following laymen speak of past surgical history (PSHx):
“balloon in my heart”
“Stents in my heart”
Heart bypass
breast removal
Part of my lung removed
Angioplasty —> PMHx CAD
Coronary Stents —-> PMHx CAD
Coronary Artery Bypass Graft (CABG) —-> PMHx CAD
Masectomy
Partial Lobectomy
Translate the following laymen speak of past surgical historys (PSHx) for the GI:
Appendix removed
Gallbladder removed
Part of my colon removed
Spleen removed
Kidney removed
appendectomy
cholecystectomy
partial colectomy
splenectomy
nephrectomy
Translate the following laymen speak of past surgical historys (PSHx) for the GU:
Uterus removed
Ovary removed
Ovary and fallopian tube removed
Prostate removed
Hysterectomy
Oophorectomy
Salpingo-oophorectomy
Prostatectomy
What does family history or FHx pertain to when determining genetic risk factors?
Parents and grandparents to include siblings.
What is the age of onset for disease that means higher genetic risk?
Under 55
What are some things that consist of Social history or SHx?
Tobacco/Alcohol/Drug Use
Occupation
Living Circumstances
Why should you pay attention to medications?
It can tell you a lot about past medical history
What is a true allergy to a medication defined as?
Medication that causes itching, swelling, difficulty breathing or rash.
Otherwise it is an “adverse reaction,” not a true allergy.
Top 10 key things to document as a scribe! (No Answer)
A provider’s INVESTIGATION of ptx
- Reviewing external records (notes or summaries from other hospitals or EMS)
- Documenting independent historians (history obtained other than the pt)
- Capturing chronic illnesses (listing comorbidities, differential dx, risk assessments)
A provider’s ACTIONS
- When drugs require intensive monitoring (what medications given and when, including any follow up)
- Independent interpretations by your provider (live discussions with other providers about test results)
- Test interpretations discussed with external provider (live discussions with other providers about test results)
A provider’s CONSIDERATIONS
- Considerations of admission or escalation of care (why a pt was escalated to ICU or considered safe to go home)
- Considerations of diagnostic tests even if not done (considering one test over another and why it was done or not. Such as CT scans)
- Prescription medications given or considered (Documenting meds considered like antibiotics even if not given, and reason)
- If patient care is affected by social determinations (documenting if a plan of care was changed or determined because of social factors that may impact health.
No Answer
Why is it so important to document everything?
To bill correctly, and for legal/historical reasons
