Course 1: Emergency Department Flow Flashcards
(171 cards)
1
Q
subjective vs. objective
A
feeling vs. fact
2
Q
chief complaint
A
the main reason for the patient’s ED visit
3
Q
medical decision making
A
the physician’s thought process
4
Q
pain vs. tenderness
A
patient’s feeling vs. physician’s assessment
5
Q
benign
A
normal, nothing of concern
6
Q
distress
A
the doctor’s judgment of discomfort
7
Q
febrile
A
the state of having a fever, concerning for infection
8
Q
acute
A
new onset, likely concerning
9
Q
chronic
A
long standing, not of direct concern
10
Q
baseline
A
an individual’s normal state of being
11
Q
auscultation
A
listening with a stethoscope
12
Q
palpation
A
the act of pressing on an area by the doctor
13
Q
inpatient
A
admitted to the hospital overnight
14
Q
outpatient
A
seen and sent home the same day
15
Q
What is a scribe?
A
an unlicensed person performing documentation and other non-clinical tasks under the direction of a licensed independent practitioner
16
Q
What are the 5 things scribes CAN do?
A
- Document the history, physical exam, results, procedures, and physician consults
- Access and document laboratory results and radiology findings
- Access and display X-rays for the physician to review
- Locate and obtain PMHx, previous charts, past results, and recent studies
- Record physician interpretations of X-rays and ECG’s
17
Q
What are the 5 things scribe CAN NOT do?
A
- Touch patients
- Write orders or prescriptions
- Give verbal orders
- Partake in any activity that may affect patient health or outcome
- Sign or authenticate any chart or record
- Handle bodily fluids or specimens
18
Q
charge nurse
A
manages the ED patient flow
19
Q
mid-level provider
A
nurse practitioner (LNP) or physician assistant (PA) that works under the supervision of a physician to diagnose and treat patients
20
Q
ED nurse
A
records medical history, symptoms, monitors the patient, starts IVs, administers medications, and assists with procedures
21
Q
respiratory therapist (RT)
A
administers “breathing treatments” and assists with managing a patient’s airway
22
Q
ED tech
A
helps the nurse and assists with procedures
23
Q
unit secretary
A
places physician’s orders, answers phone calls, pages other specialists/doctors, and organizes the patient’s paperwork
24
Q
scribe
A
documents the patient’s visit on behalf of the physician
25
What is the overview of the ED flow? (5 steps)
```
Check in and chief complain
Physician assessment
Objective orders and results
Medical decision making
Disposition
```
(CPOMD = cool physicians often make orders)
26
What is the ED flow BEFORE ORDERS?
1. Walk-In (waiting room) or EMS (ambulance bay)
2A. Triage = chief complaint, vital signs, level of activity (5 low and 1 high)
2B. Vital signs (HR, BP, RR, T, SaO2)
3. Bed placement
4. Nurse assessment (confirm chief complaint, review allergies, brief past medical history)
5. History & Physical (H&P)
5A. Subjective: HPI, ROS
5B: Past history (Hx): PMHx, PSHx, FHx, SHx
5C: Objective: physical examination (PE)
6. Physician orders
27
What is the ED flow AFTER ORDERS?
1. Differential diagnosis (DDx)
2. Physician orders
3. Laboratory studies, imaging studies, procedures, medications
4. Results & ED course: patient re-evaluations. Consults with specialists.
5. Final Dx
6. Disposition: discharge home, admit for further care, transfer to another facility
28
What is a differential dx?
Based on H&P, the physician generates a list of things that may be causing the patient's subjective symptoms.
Then the doctor places orders to "rule out" each differential
29
What does the doctor determine the final diagnosis (Dx)?
By using medical decision making (MDM), the physician reviews specific results that can rule out differential diagnoses (DDx) to reach the final diagnosis (Dx)
30
What is the general documentation template?
SUBJECTIVE COMPLAINTS:
1. HPI: history of present illness
2. ROS: review of systems
3. Past history: PMHx, PSHx, FHx, SHx
OBJECTIVE EVALUATION:
4. PE: physical examination
5. ED course: objective results (labs, imaging, re-evals, consults, procedures)
6. Disposition: discharge, admit, transfer
31
What is HPI?
history of present illness; the story and context of the patient's chief complaint
32
What is ROS?
review of systems; a head-to-toe list of positives and negatives
33
What comprises of the past history?
PMHx, PSHx, FHx, SHx
34
What is PE?
physical examination; the physician's objective findings
35
What are the possible disposition options?
discharge, admit, transfer
36
Where to document patient complaint
HPI or ROS
37
Where to document past diagnosis or surgery
past history
38
Where to document physician's observation
physical exam
39
Where to document objective study
results/ED course
40
Where to document re-evaluation
ED course
41
Where to document where they will go
diagnosis & disposition
42
The patient has a history of high cholesterol. Where would this item belong in the chart?
past history
43
The patient was given an antiemetic in the ED. Where would this item belong in the chart?
ED course
44
The EKG shows normal sinus rhythm. Where would this item belong in the chart?
Objective study = ED course
45
The patient came to the ED for chest pain. Where would this item belong in the chart?
chief complaint = HPI or ROS
46
The patient also stubbed their toe last week. Where would this item belong in the chart?
past history
47
The complete blood count (CBC) shows anemia. Where would this item belong in the chart?
objective study = ED course
48
The patient is in no acute distress. Where would this item belong in the chart?
physician's observations = physical exam
49
There is tenderness of the RUQ. Where would this item belong in the chart?
physician's observations = physical exam
50
The patient's mother has heart disease. Where would this item belong in the chart?
past history
51
Patient says: high blood pressure (general past medical history)
Scribe writes: hypertension (HTN)
52
Patient says: high cholesterol (general past medical history)
Scribe writes: hyperlipidemia (HLD)
53
Patient says; thyroid problem (general past medical history)
Scribe writes: usually hypothyroidism, sometimes hyperthyroidism
54
Patient says: diabetes (general past medical history)
Scribe writes: diabetes mellitus (DM)
55
Patient says: I only take pills for my diabetes (general past medical history)
Scribe writes: non-insulin dependent diabetes mellitus (NIDDM)
56
Patient says: I take shots (insulin) for my diabetes (general past medical history)
Scribe writes: insulin dependent diabetes mellitus (IDDM)
57
Patient says: heart disease (cardiovascular PMHx)
Scribe writes: usually coronary artery disease (CAD)
58
Patient says: heart attack (cardiovascular PMHx)
Scribe writes: myocardial infarction (MI) or CAD
59
Patient says: heart failure (cardiovascular PMHx)
Scribe writes: congestive heart failure (CHF)
60
Patient says: irregular heartbeat (cardiovascular PMHx)
Scribe writes: atrial fibrillation (A-Fib)
61
Patient says: murmur (cardiovascular PMHx)
Scribe writes: heart murmur
62
Patient says: episodes of abnormally fast/racing heartbeat (cardiovascular PMHx)
Scribe writes: supraventricular tachycardia (SVT)
63
Patient says: asthma (pulmonary PMHx)
Scribe writes: asthma
64
Patient says: emphysema/chronic bronchitis (pulmonary PMHx)
Scribe writes: chronic obstructive pulmonary disease (COPD)
65
Patient says: blood clot in lung (pulmonary PMHx)
Scribe writes: pulmonary embolism (PE)
66
Patient says: pneumonia (pulmonary PMHx)
Scribe writes: pneumonia (PNA)
67
Patient says: reflux (gastrointestinal PMHx)
Scribe writes: gastroesophageal reflux disease (GERD)
68
Patient says: ulcer (gastrointestinal PMHx)
Scribe writes: gastric ulcer or peptic ulcer disease
69
Patient says: pancreatitis (gastrointestinal PMHx)
Scribe writes: pancreatitis
70
Patient says: hepatitis (gastrointestinal PMHx)
Scribe writes: hepatitis A, hepatitis B, or hepatitis C
71
Patient says: diverticulitis (gastrointestinal PMHx)
Scribe writes: diverticulitis
72
Patient says: Crohn's/UC (gastrointestinal PMHx)
Scribe writes: Crohn's disease or ulcerative colitis
73
Patient says: irritable bowel (gastrointestinal PMHx)
Scribe writes: irritable bowel syndrome (IBS)
74
Give example of laboratory studies.
Blood work, microscopy, cultures
75
Give examples of imaging studies.
X-ray, CT, ultrasound, EKG
76
Give examples of procedures
sutures, joint reduction, splints
77
Patient says: bladder infection (genitourinary PMHx)
Scribe writes: urinary tract infection (UTI)
78
Patient says: kidney infection (genitourinary PMHx)
Scribe writes: pyelonephritis (Pyelo)
79
Patient says: kidney stones (genitourinary PMHx)
Scribe writes: renal calculi
80
Patient says: "I'm on dialysis" (genitourinary PMHx)
Scribe writes: chronic renal failure (CRF) or end state renal disease (ESRD) on dialysis
81
Patient says: enlarged prostate
Scribe writes: benign prostate hypertrophy (BPH)
82
G
gravida = total number of times the patient has been pregnant
83
P
para = the number of live births (viable children) the patient has had
84
A
abortion = the total number of miscarriages or elective abortions
85
How would you document the past history for a patient who is currently pregnant, has been pregnant three times in the past, and has two kids at home?
G: 4
P: 2
A: 1
86
Patient says: stroke (neurological PMHx)
Scribe writes: ischemic cerebrovascular accident (CVA)
87
Patient says: mini-stroke (neurological PMHx)
Scribe writes: transient ischemic attack (TIA)
88
Patient says: seizures (neurological PMHx)
Scribe writes: seizure disorder/epilepsy
89
Patient says: brain blood (neurological PMHx)
Scribe writes: hemorrhagic CVA
90
Patient says: bipolar (psychological PMHx)
Scribe writes: bipolar disorder
91
Patient says: schizophrenia (psychological PMHx)
Scribe writes: schizophrenia
92
Patient says: "I drink a lot" (psychological PMHx)
Scribe writes: EtOH abuse or alcoholism
93
Patient says: "I do drugs" (psychological PMHx)
Scribe writes: substance abuse
94
Patient says: "blood clot in my leg" (vascular PMHx)
Scribe writes: lower extremity deep vein thrombosis (DVT)
95
Patient says: "bulge in my aorta" or "triple A" (vascular PMHx)
Scribe writes: abdominal aortic aneurysm (AAA)
96
Patient says: "bad blood flow to my legs" (vascular PMHx)
Scribe writes: peripheral vascular disease (PVD)
97
Patient says: "numbness in my legs" (vascular PMHx)
Scribe writes: peripheral neuropathy
98
Patient says: low back pain (musculoskeletal PMHx)
Scribe writes: chronic low back pain
99
Patient says: bulging/herniated disc (musculoskeletal PMHx)
Scribe writes: degenerative disc disease (DDD)
100
Patient says: arthritis (musculoskeletal PMHx)
Scribe writes: usually osteoarthritis (OA) sometimes rheumatoid arthritis (RA)
101
Patient says: joint pain (chronic) (musculoskeletal PMHx)
Scribe writes: degenerative joint disease (DJD)
102
Patient says: weak/fragile bones (musculoskeletal PMHx)
Scribe writes: often osteoporosis
103
Patient says: cancer (cancer PMHx)
Scribe writes: cancer or carcinoma (CA): brain, breast, lung, colon, prostate, ovarian, skin, bone, leukemia, or lymphoma
104
Patient says: spread to my... I (cancer PMHx)
Scribe writes: with metastases to the...
105
Patient says: chemo (cancer PMHx)
Scribe writes: chemotherapy
106
Patient says: radiation (cancer PMHx)
Scribe writes: radiation therapy
107
Patient says: they cut it out (cancer PMHx)
Scribe writes: status-post surgical reaction
108
Patient says: it's gone (cancer PMHx)
Scribe writes: in remission
109
Patient says: tonsils removed (throat PSHx)
Scribe writes: tonsillectomy
110
Patient says: adenoids removed (throat PSHx)
Scribe writes: adenoidectomy
111
Patient says: ear tubes (throat PSHx)
Scribe writes: pressure equalizer (P.E.) tubes
112
Patient says: heart bypass (cardiovascular PSHx)
Scribe writes: coronary artery bypass graft (CABG) > PMHx CAD
113
Patient says: stents (cardiovascular PSHx)
Scribe writes: coronary stents > PMHx CAD
114
Patient says: heart cath (cardiovascular PSHx)
Scribe writes: cardiac catheterization
115
Patient says: balloon (cardiovascular PSHx)
Scribe writes: angioplasty > PMHx CAD
116
Patient says: valve surgery (cardiovascular PSHx)
Scribe writes: valve repair or replacement (bovine vs. mechanical)
117
Patient says: pacer (cardiovascular PSHx)
Scribe writes: pacemaker
118
Patient says: defibrillator (cardiovascular PSHx)
Scribe writes: automatic implanted cardiac defibrillator (AICD)
119
Patient says: surgery for A Fib (cardiovascular PSHx)
Scribe writes: Afib s/p cardiac ablation
120
Patient says: breast removal (pulmonary/chest PSHx)
Scribe writes: mastectomy
121
Patient says: hole in my neck (pulmonary/chest PSHx)
Scribe writes: tracheostomy (commonly called a "trach")
122
Patient says: part of my lung removed (pulmonary/chest PSHx)
Scribe writes: partial lobectomy
123
Patient says: appendix removed (gastrointestinal PSHx)
Scribe writes: appendectomy
124
Patient says: gallbaldder removed (gastrointestinal PSHx)
Scribe writes: cholecystectomy
125
Patient says: hernia repair (gastrointestinal PSHx)
Scribe writes: herniorrhaphy
126
Patient says: part of my colon removed (gastrointestinal PSHx)
Scribe writes: partial colectomy
127
Patient says: bag to collect stool (gastrointestinal PSHx)
Scribe writes: colostomy
128
Patient says: spleen removed (gastrointestinal PSHx)
Scribe writes: splenectomy
129
Patient says: stomach staple (gastrointestinal PSHx)
Scribe writes: gastric bypass
130
Patient says: exploratory (gastrointestinal PSHx)
Scribe writes: exploratory laparoscopy (ExLap)
131
Patient says: kidney removed (genitourinary PSHx)
Scribe writes: nephrectomy
132
Patient says: uterus removed (genitourinary PSHx)
Scribe writes: hysterectomy (partial vs. total)
133
Patient says: ovary removed (genitourinary PSHx)
Scribe writes: oophorectomy
134
Patient says: ovary and fallopian tubes removed (genitourinary PSHx)
Scribe writes: salpingo-oophorectomy
135
Patient says: tubes tied (genitourinary PSHx)
Scribe writes: tubal ligation (female) or vasectomy (male)
136
Patient says: C-section (genitourinary PSHx)
Scribe writes: Caesarean section
137
Patient says: prostate removed (genitourinary PSHx)
Scribe writes: prostatectomy (most often trans-urethral removal of the prostate, or TURP)
138
Patient says: uterine product removed (genitourinary PSHx)
Scribe writes: dilation and curettage (D&C)
139
Patient says: neck artery cleaned (neurological PSHx)
Scribe writes: carotid endarterectomy
140
Patient says: brain surgery (neurological PSHx)
Scribe writes: crainotomy (brain bleed vs. brain CA)
141
Patient says: shunt (neurological PSHx)
Scribe writes: ventriculoperitoneal (VP) shunt
142
Patient says: dialysis fistula (vascular PSHx)
Scribe writes: AV (arteriovenous fistula)
143
Patient says: dialysis graft (vascular PSHx)
Scribe writes: AV graft
144
Patient says: PICC line (vascular PSHx)
Scribe writes: peripherally inserted central catheter (PICC)
145
Patient says: port (vascular PSHx)
Scribe writes: Port-a-cath or medi-port
146
Patient says: clot filter (lower abdomen) (vascular PSHx)
Scribe writes: IVC (inferior vena cava) filter
147
Patient says: clot filter (leg0 (vascular PSHx)
Scribe writes: Greenfield filter
148
Patient says: leg amputated (orthopedic PSHx)
Scribe writes: above knee amputation (AKA) or below knee amputation (BKA)
149
Patient says: joint repair (orthopedic PSHx)
Scribe writes: arthroplasty
150
Patient says: metal plates/pins (orthopedic PSHx)
Scribe writes: hardware
151
Patient says: neck fused (orthopedic PSHx)
Scribe writes: cervical spinal fusion
152
Patient says: back fused (orthopedic PSHx)
Scribe writes: lumbar spinal fusion
153
Patient says: hip surgery (orthopedic PSHx)
Scribe writes: open reduction with internal fixation (ORIF)
154
What is a true allergy?
Any medication that causes a rash, itching, swelling, or difficulty breathing. Otherwise, it's an "adverse reaction", not a true allergy
155
What is important to family history and why?
The age of onset b/c it helps determine the genetic risk factor
156
Younger age of onset means...
Higher genetic risk
157
Older age of onset (50 y/o + ) is...
more likely due to environment than genetics
158
The genetic risk for the disease is higher if...
multiple blood-family members suffer from the same disease
159
FHX general (3)
HTN
DM
CA
160
FHx cardiac (1)
MI/CAD less than 55 y/o
161
FHx pulmonary (2)
PE
| Asthma
162
FHx gastrointestinal (2)
Crohn's
| IBS
163
FHx neurological (3)
CVA
Aneurysm
Seizures
164
FHx miscellaneous (2)
Sickle cell anemia
| DVT
165
What are the 5 factors pertaining to social history (SHx)?
```
(TAIL O)
Tobacco use
Alcohol use (EtOH)
Illicit drug use
Living circumstances
Occuptation
```
166
What must be recorded in SHx for tabacco use?
```
Smoking status
> Current (#ppd, #yrs)
> Former (year quit)
> Never
> Second-hand exposure (pediatrics)
```
Chewing tabacco
167
What must be recorded in SHx for alcohol use?
```
Never
Occasionally/socially
Daily
Chronic alcoholic
> Number of drinks/day
> Type of alcohol (beer/wine/liquor)
```
168
What must be recorded in SHx for illicit drug use?
```
Which drug
> Heroin
> Cocaine
> Methamphetamine
> THC
> Narcotics
```
Route of administration
> Oral
> Inhaled
> Injected
Date of last use
169
What must be recorded in SHx for occupation?
Employed
Unemployed
On disability
Retired
If a physician asks specifically about type of work, be sure to document it.
170
What must be recorded in SHx for living circumstances?
```
Lives alone
With family/friends
Nursing home/assisted living
Hospice
Homeless/shelter
```
171
What must be recorded in SHx for pediatrics? (Unique to pediatric patients)
```
Caretaker (mother, father, etc.)
Attends daycare
Attends school
Has brothers/sisters
Second-hand smoke exposure
Immunizations up to date
```
