Chief Complaint
the main reason for the pt's ED visit
pain vs tenderness
pt's feelings (subjective) vs physician's assessment
... [Show More] (objective)
distress
the doctor's judgement of discomfort
baseline
an individual's normal state of being
What CAN scribes do?
-Document Hx, PE, results, procedures, and physician consults
-Access and document lab results and radiology findings
-Locate and obtains PMHx, previous charts, past results, and recent studies
-Record physician interpretations of x-rays and EKGs
What can scribes NOT do?
-Touch pts
-Write orders or Rxs
-Give verbal orders
-Partake in any activity that may affect pt health/outcome
-Sign or authenticate any chart/record
-Handle bodily fluids or specimens
What does the Charge Nurse do?
Manages ED pt flow
What does the ED Nurse do?
Records medical Hx, symptoms, monitors pt, starts IVs, administers medications, and assists with procedures.
What does the Unit Secretary do?
Places physician's orders, answers phone calls, pages other specialists/doctors, and organizes pt's paperwork.
What does the scribe do?
Document pt's visit on behalf of the physician.
What is the ED flow?
Walk in → triage → bed → physician assessment → labs/rad/meds → results → MDM → diagnosis → consults → disposition
What are the 5 vital signs?
-RR
-BP
-HR
-temp
-O2 sat
Level of acuity
5 (low) to 1 (high)
What are all the parts of the chart?
-HPI
-ROS
-Past Hx
-PE
-ED Course
-Disposition
What goes in each SOAP section?
S: HPI and ROS
O: PE and ED course
A: diagnosis
P: plan and disposition
Pt says "high blood pressure," you write...
hypertension (HTN)
Pt says "high cholesterol," you write...
hyperlipidemia (HLD)
Pt says "diabetes," you write...
diabetes mellitus (DM)
Pt says "I take pills for my diabets," you write...
non-insulin dependent diabetes mellitus (NIDDM)
Pt says "I take shots (insulin) for my diabetes," you write...
insulin dependent diabetes mellitus (IDDM)
Pt says "heart disease," you write...
coronary artery disease (CAD)
Pt says "heart attack," you write...
myocardial infarction (MI) and CAD
Pt says "heart failure," you write...
congestive heart failure (CHF)
Pt says "irregular heartbeat," you write...
atrial fibrillation (a fib) or arrhythmia
Pt says "murmur," you write...
heart murmur
Pt says "abnormally fast/racing heartbeat," you write...
supraventricular tachycardia (SVT) or arrhythmia
Pt says "emphysema/chronic bronchitis," you write...
chronic obstructive pulmonary disease (COPD)
Pt says "blood clot in lung," you write...
pulmonary embolism (PE)
Pt says "pneumonia," you write...
pneumonia (PNA)
Pt says "reflux," you write...
gastroesophageal reflux disease (GERD)
Pt says "ulcer," you write...
gastric ulcer or peptic ulcer disease (PUD)
Pt says "kidney stones," you write...
renal calculi
Pt says "I'm on dialysis," you write...
chronic renal failure (CRF) or end stage renal disease (ESRD) on dialysis; include how often and when they go
Describe what G/P/A means.
G: how many pregnancies
P: how many live births
A: how many abortions/miscarriages
Pt says "stroke," you write...
CVA
Pt says "mini stroke," you write...
TIA
Pt says "brain bleed," you write...
hemorrhagic CVA
Pt says "I drink a lot," you write...
ETOH abuse/alcoholism
Pt says "I do drugs," you write...
substance abuse
Pt says "blood clot in leg," you write...
LE DVT
Pt says "bulge in my aorta/triple A," you write...
abdominal aortic aneurysm (AAA)
Pt says "tonsils removed," you write...
tonsillectomy
Pt says "heart bypass," you write...
coronary artery bypass graft (CABG) w/ PMHx of CAD
Pt says "breast removal," you write...
mastectomy
Pt says "part of my lung removed," you write...
partial lobectomy
Pt says "appendix removed," you write...
appendectomy
Pt says "gallbladder removed," you write...
cholecystectomy
Pt says "part of colon removed," you write...
partial colectomy
Pt says "bag of stool," you write...
colostomy
Pt says "stomach stapled," you write...
gastric bypass
Pt says "kidney removed," you write...
nephrectomy
Pt says "uterus removed," you write...
hysterectomy (partial or total)
Pt says "tubes tied," you write...
tubal ligation (f) or vasectomy (m)
What are the 4 signs of a true allergy?
-rash
-itching
-swelling
-difficulty breathing
What is it called when a medication causes a non-true allergy?
adverse reaction
What are the 3 routes of drug administration?
-oral
-inhaled
-injected
What are the 3 types of dispositions?
-discharged
-admitted
-transferred to another facility/dept
The diseases being considered as the source of the symptoms
differential diagnoses (DDX)
Specific symptoms that are NOT present which causes the physician to rule out certain diagnoses
pertinent negatives
Chief complaint of CAD
chest pain/pressure worse with exertion; improved by rest or nytroglycerin (NTG)
Associated meds of CAD
Aspirin 324 mg PO or NTG (blood thinners)
How is CAD diagnosed?
cardiac catheterization (not in ED)
Associated symptoms of MI
-chest pain
-N/V
-SOB
What are the 6 risk factors for MI?
-CAD
-HTN
-HLD
_DM
-smoker
-FHx <55 y.o.
How is MI diagnosed?
EKG (STEMI) elevated troponin (non-STEMI)
Associated meds of MI
Heparin
What are 3 PE findings of CHF?
-rales
-jugular vein distension (JVD)
-pitting pedal edema
How is CHF diagnosed?
-CXR
-elevated BNP
What is a PE finding of AFib?
irregularly irregular rhythm [Show Less]