What do you document for a syncope patient?
How do you feel before?
How do you feel during?
How do you feel after?
How do you feel now?
When a
... [Show More] physician does a check for a pronator drift, and checks the CN - 111, where should you document the results?
Neurological / Cerebellar / Coordination
Chest pain (bonus question)
MI
Aortic Dissection
Lower abdomen (bonus question)
cholecystitis
ruptured appendicitis
Dynspena (bonus question)
Pneumothorax
pulmonary embolism
Test(s) done to diagnose SBO
-CT A/P with PO
-acute abdominal series (AAS)
What's PHI?
-anything that can expose the patient's identity
-name, date, reason for visit, etc.
Test(s) done to diagnose appendicitis
CT A/P with PO contract
Test(s) done to diagnose cholecystitis
abdominal US of RUQ
Test(s) done to diagnose meningitis
LP
Test(s) done to diagnose hemorrhagic CVA
CT Head
LP
Test(s) done to diagnose CHF
CXR
Elevated BNP
Test(s) done to diagnose PE
CTA Chest/ VQ scan
(D-dimer ONLY rules out)
What is it called when you get your kidney removed?
nephrectomy
You see a fellow scribe helping a patient up from their bed, what do you do?
Tell your chief scribe!
physician says right wrist is fine, what do you write?
Right radial pulse 2+
RLQ pain indicates
appendicitis
RUQ pain indicates
cholecystitis
LLQ pain indicates
diverticulitis
LUQ pain indicates
pancreatitis
physician says top of left foot pulse is fine, what do you write?
Left DP pulse 2+
physician says left heel pulse is fine, what do you write?
Left PT pulse 2+
physician says neck pulse is fine, what do you write?
Carotid pulse 2+
MOI
mechanism of injury
LAD
left axis deviation
RAD
right axis deviation
RBBB
right bundle branch block
SVT
superventricular tachycardia
PVC
premature ventricular contraction
ST^ (up arrow)
acute ST elevation
LAFB
left anterior fascicular block
1 degree AVB
first degree AV block
how many elements are in a PE?
10 elements
Guarding, rebound tenderness, rigidity all occurs in what area?
abdominal / abdomen
What are the three main cardiac risk factors?
HTN
HLD
DM
(also smoking)
Spell out CT A/P
computerized tomography of abdomen/ pelvis
level five coding includes ow many elements for billing?
HPI
ROS
PMH/SH
PE
hpi-4
ros-10
pmh-2
pe-8
what is increased breathing rate called?
tachypnea
what are the effects of the neurological function?
FND
changes in...
-motor strength
-sensation
-speech
-vision
Pt is experiencing artery blockage of blood to the brain causing lack of O2. What would your Dx be?
Ischemic CVA
EOMI
extraocular movements intact [Show Less]