You quickly look up the information on your laptop and tell the physician that the labs came back normal except for a blood glucose level of 356, so your provider subsequently asks you to tell the nurse to start that patient on an insulin drip. It is a vasodilator - expands the blood vessels. Well developed, Well nourished, No acute distress. Line that divides the body into right and left halves. How many minutes of Critical Care Time were provided? Follow up, Time period in which to follow up, Specific conditions for return to ED, Condition: stable for discharge, Time of disposition. A patient states she has had a productive cough for 4 days, and yesterday she developed a fever. Which of the following lab results need to be monitored closely for efficiency? What is a medical term for "sweating heavily"? In a physical exam, what does "TTP" mean? Heart Rate, Blood Pressure, Respiratory Rate, Temperature, Oxygen Saturation. The ED chart is incomplete and does not accurately reflect the level of care provided. Instead, we would count back the number of days and document this numerically. (Select the best response.). What is one test/lab that will never result during a patient's ED visit? ABD PAIN: "Blood in vomit or stool" is a red flag for.. ABD PAIN: "Dizziness" is a red flag for.. GI bleed, Abdominal Aortic Aneurysm - AAA. What is the chief complaint of someone with COPD? For chest pain patients, administering this medication can prevent onset of MI by thinning out the blood and improving blood flow to the heart. Nephrolithiasis, Renal Calculi, Urolithiasis. AMS is generalized and typically caused by something and typically caused by something that can affect the whole brain - drugs, low BS. Which action would you include? Because it is less likely that their current Sx are life threatening if they have survived similar Sx in the past, What should you focus on when writing an HPI? LOC, head injury, neck pain, back pain, numbness, weakness, It is the story of the Sx and events that led to the patient's ED visit. tissue Plasminogen Activator, it is a medication that dissolves blood clots. Must have Rate, rhythm, and at least 2 other findings. What is the medical term for "low glucose"? Differential Dx 2. Certain words or phrases act as "red flags" to grab your provider's attention to let let them know that a patient may require timely and comprehensive medical action. How does Aspirin (ASA) benefit a potential MI or CAD? BMP- Basic Metabolic Panel contains electrolytes, kidney function, and glucose levels. What is the medical term for "pus in tonsils"? Yes, because the fever started soon after the cough. What is the benign "no touch" exam for the GI system? Fat is used for fuel instead and produces ketones. Positive for a blood clot; possible PE, must order a CTA Chest or VQ Scan, PT-prothrombin time, PTT-partial thromboplastin time, INR-international normalized ratio. You see the physician check the patient's pulses in four places; the right wrist, the top of the right foot, the back of the right foot and the left neck. Match the oxygen administration route to the corresponding definition. Match the location with the appropriate pulse that you would document in the physical exam? (select all that apply), Which of the following would NOT be considered an example of PHI? What DDx would your provider be concerned about? What cardiac enzyme is more specific to heart damage? You are writing an HPI for a very complex patient who has had multiple recent hospital admissions and several significant complaints; what is the best way to organize the information in your HPI? Has George taken the appropriate steps in this situation? Results and ED course 4. While your provider is prepping the critical patient for a procedure, she asks you to look up the CBC result on another patient. What is the ED flow after orders are made? Your physician tells you the patient had a wood's lamp exam to look for fluorescein uptake. Headache and neck pain; fever, neck stiffness, AMS. What is/are the chief complaints of a patient with Altered Mental Status (AMS)? Sterile technique: cap, mask, sterile gown, sterile gloves, sterile sheet, hand hygiene, 2% chlorohexidine, A body of laws designed to protect private health information of patients, Privacy laws related to electronic transmission of health information, Major Sx, Chest Pain/SOB, Discussed Risks/Benefits/Alternatives, Procedures, Consent, Female/Male Chaperone Present, Unique Physical Exam Identifiers, Times, Orders per Consults, General, Organic, and Biological Chemistry, Fundamentals of General Organic and Biological Chemistry, Carl A. Hoeger, David S. Ballantine, John E. McMurry, Virginia E. Peterson. Yellowing of the eyes, indicates liver failure. In a CBC, what does "low platelets" (Thrombocytopenia) tell us? Document "last known well" date and time. If a doctor says "Sinus Brady" what do you write? An abscess IS cellulitis with fluctuance - pus pocket. No, because George accessed his own medical record using his EMR login. What would dry mucous membranes indicate? Consent should be documented any time a procedure is performed, but there maybe certain situations in which consent is unobtainable. What is the benign "touch" exam for the Neck system? combination of (+) EKG and (+) blood work : STEMI. Pain Assessment. Use the abbreviation to answer the question. What is the medical term for "low bicarbonate"? You are administering supplemental oxygen to a child using the blow-by technique. Cardioversion, central line placement, endotracheal intubation, chest tube placement. ), b) Documenting the answers to every question asked by the doctor. What is the core measure for Acute Otitis Externa (Outer Ear Infection)? What is the action of Fentanyl and what is the onset and duration. The Emergency Department is extremely busy, and so George decides to help out the doctor by scribing his own note using the computer in the room. What is the core measure for Acute Pulmonary Embolism? Match each critical care dx with it's associated procedure. How is AMS different from Focal Neuro Deficit (FND)? What PE finding is important for your provider to assess and include in the procedure note before the patient can be discharged home? In a Differential (includes CBC), what does "High Segs / Segmented Neutrophils" tell us? Which of the following words or phrases are NOT considered a "red flag? Read through the PE and decide if this meets Level 5 billing criteria. What condition correctly describes "Fertilized egg develops outside the uterus"? An ROS has marked positive for head trauma with accompanying LOC. What does "Fluorescein uptake" during a physical exam mean? What is the medical term for "high potassium"? Room Air, Nasal Cannula, Facial Mask,Non-Rebreather Mask. Elevated Lipase or Amylase which is less specific. The doctor states "The pulses are fine". What does Mechanism of Injury (MOI) mean? less than full alertness, altered level of consciousness, Physical waisting with loss of weight and muscle mass due to disease, rapid swelling - most commonly eyes or lips. What type of image do ED physicians interpret? - Scribe: Documents the patient's visit on behalf of the physician, What FHx/SHx information is usually asked for pediatric patients? Quality is an important descriptor that can paint a picture for concerning DDx. Which of the following would belong in a psychiatric exam? A female patient has been pregnant four times in the past, is currently pregnant, and has two children at home. What are the only Sx of a true allergic reaction? CHEST PAIN: "Shortness of Breath" is a red flag for.. Medical Decision Making 5. What are the risk factors associated with Pulmonary Embolism? An accumulation of blood in the anterior chamber of the eye. He was off today and accidentally cut his cheek while practicing his sword swallowing skills. Medical terminology. What is the normal Oxygen Saturation range? FEMALE LOWER ABD PAIN: "Suprapubic pain" is a red flag for.. Physician assessment 3. How does Nitroglycerin (NTG) benefit a potential MI or CAD? What medical term describes "noticeable blood in the urine"? 2. Document tPA eligibility - within 3 hours of onset. Calculate the G, P and A, respectively. Identify the error in this sentence from an example HPI: "Patient states the CP has been intermittent since Thursday. Brachial pulse, Radial pulse, Carotid pulse, Femoral pulse, Dorsalis Pedis pulse, Posterior Tibialis pulse. What is the benign "no touch" exam for the Respiratory system? A vascular change that temporarily deprives a part of the brain of oxygen but does not result in any long lasting deficits"? What section of the physical exam would you document "RUE strength 3/5" under? Blood cultures. If a doctor says "Nothing acute" for an EKG, what do you write? Pertaining to the palm of the hand or the sole of the foot. Name 4 causes of Altered Mental Status (AMS)? ", Which section of the chart would you find AKA? That all final diagnoses are based off of documentation somewhere else in your chart. Would her fever be considered an associated symptom for her productive cough? In the neurological exam, what does "normal gait" mean? ), Yes, because the phone is not an approved hospital device and it is not encrypted. A patient is seen in the emergency department complaining of dysuria and tells you that she is 23 weeks pregnant. In what body system would you document "TM erythema and bulging"? (select all that apply.). What type of information are the HPI and ROS? Splinting, joint reduction, Arthrocentesis. What does PTA (infection) stand for and what is it? What is/are the chief complaint(s) of Cholelithiasis and Cholecystitis? Your provider is busy dealing with a crtically ill patient and during this time the ED starts to pick up pace as more patients arrive. Based on this information which is the most likely final diagnosis for the patient? What is the core measure for Ischemic CVA? What is/are the chief complaints of Small Bowel Obstruction? How many tubes of CSF are typically obtained during a Lumbar Puncture? What must happen on ALL EKG documentation in order for the physician to be reimbursed for their interpretation? Swelling of the head of the optic nerve, a sign of increased intracranial pressure. Allergic reaction can only be these 3 things: rash, itching, swelling. Name 2 "Peritoneal Signs" in the abdominal exam? What are we worried about for someone with a GI bleed? ), Which of the following tests would likely be immediately ordered for a Cardiac Workup in the ED? RUQ pain; sharp, worsened with eating, deep breaths, and palpation. In the psychiatric exam, what do SI and HI stand for? It is when the EKG shows "ST segment elevation" it indicates an acute heart attack. Abx selection and timing. turning of the hand so the palm faces downward, situated behind or directed towards the rear, physician taps on a surface to determine the underlying structure, Physician listens to the internal sounds of the body using a stethoscope, Physician feels the different parts of the body, Premature death of cells in living tissue, surgically created opening connecting an internal organ to the surface of the body, Tissue death caused by a local lack of oxygen due to obstruction of the tissue's blood supply, Decrease in the blood supply to a bodily organ, tissue, or part caused by constriction or obstruction of the blood vessels, Malnutritioned, wasting, or in poor health, vital signs taken sitting, standing, and supine, methycillin resistant staphylococcus aureus; one strain of the staphylococcus bacteria that is resistant to medications conventionally used to treat it. In a Differential (includes CBC), what does "High Lymphs / Lymphocytes" tell us? What do "CRP" and "ESR" mean and what do they test for? Non-specific test used to help rule out PE or DVT. What are the possible consequences of a HIPAA violation? The doctor tells you there is no tendon injury and circulatory, sensory and motor is intact. If a doctor says "V one, V two, or V three" what do you write? If a doctor says "Sinus at 72 (between 60 and 100bpm)" what do you write? What is the medical term for stones in the gallbladder? Epigastrium, RUQ, LUQ, RLQ, LLQ, Suprapubic, Periumbilical, Right/Left Flanks, Bile emulsifies the fats in foods. What is the medical term for "black eye"? what is the cellular death necrosis process? What is the core measure for Chest Pain (Non-Traumatic)? How is CAD (major risk factor for MI) diagnosed? What general area of the body does Cranial Nerves (CN) control? What is the medical term for infection of the gall bladder? If a doctor says "Left Axis" for an EKG, what do you write? What is a pre-existing condition you must have before you can get diverticulitis? Match the following HPI detail with the corresponding DDx. What are signs of a Peri-Tonsillar Abscess (PTA)? Which of these procedures qualify as critical care procedures and would indicate that critical care time must be documented on a patient? What are important things to document for an Ischemic CVA? If the physician checks the pulse on the right wrist and says "The pulses are fine," what would you document in the physical exam? Expand the following PMHx abbreviation into the full medical term. What are the risk factors associated with COPD? What is the ED flow before orders are made? DIZZINESS/HEADACHE: "Difficulty with balance" is a red flag for.. DIZZINESS/HEADACHE: "Fever" is a red flag for.. DIZZINESS/HEADACHE: "Neck pain" is a red flag for.. DIZZINESS/HEADACHE: "Altered Mental Status" is a red flag for.. DIZZINESS/HEADACHE: "Worst headache of life/ Thunderclap onset" is a red flag for.. DIZZINESS/HEADACHE: "Syncope or seizure" is a red flag for.. SYNCOPE: "Tongue bite wound" is a red flag for.. SYNCOPE: "Numbness/Weakness/Tingling" is a red flag for.. SYNCOPE: "Changes in speech or vision" is a red flag for.. SYNCOPE: "Chest pain" is a red flag for.. SYNCOPE: "Shortness of Breath - SOB" is a red flag for.. SYNCOPE: "Palpitations" is a red flag for.. AMS: "Numbness/Weakness/Tingling" is a red flag for.. AMS: "Changes in speech or vision" is a red flag for.. AMS: "Hx of depression or drug abuse" is a red flag for.. AMS: "Hx of Diabetes" is a red flag for.. TRAUMA: "Loss of Consciousness - LOC" is a red flag for.. TRAUMA: "Unilateral Numbness/Weakness/Tingling" is a red flag for.. TRAUMA: "Bilateral Numbness/Weakness/Tingling" is a red flag for.. TRAUMA: "Neck pain or back pain" is a red flag for.. TRAUMA: "Shortness of Breath - SOB or Chest Pain - CP" is a red flag for.. TRAUMA: "Abdominal pain" is a red flag for.. GERD, AAA, Pancreatitis, Hepatitis, Deveticulitis, Kidney stones, UTI, Renal insufficiency/failure, CVA, TIA, Epilepsy/Seizure, Migraines, Dementia, Alzheimer's, Depression, Anxiety, Bipolar, Schizophrenia, Tonsillectomy, Adenoidectomy, Pressure Equalization tubes, CABG, Coronary Stents, Pacemaker, AICD, Catheterization, Angioplasty, Valve replacement, Automatic Implantable Cardioverter Defibrillator, Appendectomy, Cholecystectomy, Herniorrhaphy, Gastric Bypass, Colectomy, Colostomy, Nephrectomy, Hysterectomy, C-section, Oophorectomy, Salpingo-oophorectomy, Tubal ligation, TURP, AKA - Above the Knee Amputation, BKA - Below the Knee Amputation, Carotid Endarterectomy, Craniotomy, VP shunt, a surgical procedure used to reduce the risk of stroke by correcting stenosis (narrowing) in the common carotid artery or internal carotid artery, Peripherally Inserted Central Catheter - is a thin, soft, flexible tube - an IV line, The flow of blood through the body's blood vessels, Glasgow Coma Scale, used to assess level of consciousness in trauma patients. "I take shots (insulin) for my diabetes" means.. Insulin Dependent Diabetes Mellitus - IDDM. What is the general documentation template? What does "PE" stand for in the Diagnosis section of the chart? A full examination is unable to be obtained due to clinical condition. Creatinine must always be done first due to IV contrast in the CTA stressing the kidneys, Acute Abdominal Series/Kidneys Ureters Bladder - series of 3 XR's taken to check for Free air- rupture, SBO, constipation, large kidney stones. No guarding, rebound, or rigidity. Peritonsillar Abscess, forms in the tissues of the throat next to one of the tonsils. Match the following description to the appropriate team member. What is the chief complaint of someone with Pneumonia? NSR at a rate of 80bpm, no acute ST/T changes. How to make sure the PMHx is coded at a "level 5"? The patient also appears to be lethargic with obvious lacerations above her right eyebrow, left hand, and left thigh. What does it indicate if the pt has pale conjunctiva? What is the medical term for "Swollen lymph nodes"? Soft. Pupils are Equal Round and Reactive to Light. Chest pains when taking a deep breath: PTX. Make sure the ROS has at least 10 elements or 2 elements and the - All systems negative box checked. What is the medical term for "swollen lymph nodes"? He goes to the Emergency Department and is seen by a doctor and another scribe. Why or why not? What needs to happen with patients who have both cardiac risk factors and epigastric pain? All symptoms documented in the HPI are also documented in the ROS. What is the medical term for "low sodium"? Select terms you might find on an x-ray interpretation. What is the biggest concern with a "sore throat"? What are the 3 labs that are important to track for efficiency? What is an important thing to document for Bell's Palsy? Which of these 2 physical exam findings could a physician appreciate without auscultating the patient's lungs? (select the best option. What type of patient is the Glasgow Coma Scale (GCS) associated with? Elderly, bedridden, recent chest injury, recent surgery, Collapsed lung do to trauma or a spontaneous small rupture of the lung. The first patient is presenting with a productive cough steadily worsening since onset 4 weeks ago. Inflammation of the walls of the lymphatic vessels, The separation of any part of the body from the whole. Which of the following are considered to be cardiac risk factors for CP patients? What are the associated diseases of the RLQ? What does "hyphema" mean in a physical exam? What must you document when dealing with a PTX pt? What does "Papilledema" mean in physical exam? What is all included in the Cardiac Enzyme Panel (CEP)? Procedure of using a syringe to collect synovial fluid from a joint capsule. Your physician verbalizes outloud that the patient appears to be on a backboard and her cervical spine is stabilized with a hard collar. FND are localized - weakness, numbness, speech, vision - to one specific area and corresponds with damage to a specific spot in the brain. metacarpophalangeal joint-large, at the base of the fingers. - Non-rebreather mask: A facial mask with a reservoir bag attached. What is the main concern with an allergic reaction? A 43-year-old male presents to the ED with vomiting that began 5 hours ago. What condition correctly describes "An immune response that leads to rash, itching, swelling, or difficulty breathing"? 1. How is an abscess different from cellulitis? what are the main 2 priorities of care with patients with fistulas? What are the risk factors associated with Pneumonia? Match the normal grading scale with the corresponding PE finding. CHEST PAIN: "Radiation to back" is a red flag for.. If a doctor says "Normal EKG at 80 (bpm)" what do you write? Which of the following diseases may be diagnosed using a CXR? Widened and weakened arterial wall at risk of rupture, Separation of the muscular wall from the membrane of the artery, putting the pt at risk of aortic rupture and death. What is the difference between a CTA and a CT? What would a "Guaiac positive" stool sample diagnose? CMP- Comprehensive Metabolic Panel is a BMP including LFTs. Vital signs, O2Sat, Mental Status. Now that the results are back, the physician will be ready to discharge the patient home. Expand the following medical abbreviation. How is Small Bowel Obstruction (SBO) diagnosed? Patient's feeling vs. physician's assessment, The act of pressing on an area by the doctor, 1. No, the PE does not meet Level 5 billing criteria. What is the benign "no touch" exam for the Neurological system? What is the medical term for "carotid artery cleaning"? Regular rate and rhythm. What are the associated diseases of the Periumbilical region? What are the risk factors associated with a Myocardial Infarction (MI)? Cholelithiasis, Cholecystitis, Gallbladder wall thickening, bile sludge, bile duct obstruction. In a Differential (includes CBC), what does "High Eos / Eosinophils" tell us? Does this patient qualify for Critical Care? The second patient has had abdominal discomfort slowly localizing into the right lower abdomen with accompanying fever over the last 6 hours and on PE, the patient has RLQ tenderness on palpation. MOI, How it occurred, when it occurred, and what surface did they land on. What must you remember to document if a patient is discharged home? George is employed with SA as a scribe. tPA eligibility, date and time the pt "last felt well/normal". What does tPA stand for and what does it do? CT A/P with PO Contrast, Acute Abdominal Series (AAS). HINT: it's an abbreviation. (select all that apply), You've just caught up on all of your charting. What subcategories are included in within the Past History section of the template? What medical term would you use to describe a "runny nose"? Match location with the corresponding DDx. Hematemesis, coffee ground emesis, hematochezia, melena, Guaiac positive or Heme + stool, gastroccult. ), A consultation note indicating the admitting physician. What are the associated diseases of the LUQ? What is a STEMI (ST Elevation Myocardial Infarction)? Your doctor diagnoses her with a UTI. (Select all that apply.). What ROS system would include Dyspepsia, the medical term for indigestion? What might a person with kidney stones c/o? What is the normal INR for a patient that is on blood thinners? It is stored in the gallbladder and made in the liver. The spine is often immobilized with a C-collar and backboard. If a doctor says "Non specific changes" what do you write? What is the medical term for "high chloride"? Physical exam is positive for Romberg's and Head CT is negative. CHEST PAIN: "Recent trauma" is a red flag for.. Make sure the PMHx has at least 2 elements. What is the abbreviation for Nitroglycerin? Arrival 2. Name a type of Orthopedic procedure that may be performed by the EP? Rapid heart rate (subjective irregularity), electrocardiogram-transthoracic interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body, ejection fraction-volume of blood pumped from the left and right ventricles with each heart beath, paroxysmal nocturnal dyspnea-sudden, severe shortness of breath that usually occurs at night and wakes a person from sleep, chest pain or discomfort that occurs when an area of your heart muscle doesn't get enough oxygen rich blood, blood vessels that carry blood away from the heart, blood vessels that carry blood to the heart, extra heart sound called S3 or S4 dependent upon where in the cycle this added sound comes, swelling of tissue due to excess accumulation of fluid, Chest pain that is elicited by palpating the chest, jugular vein distension-bulging of veins in the neck, abdominal aortic aneurysm-localized dilation (ballooning) of the abdominal aorta exceeding the normal diameter by more than 50%, and is the most common form of aortic aneurysm, bundle branch block-refers to a defect of the heart's electrical conduction system that can be seen on an EKG, coronary artery bypass graft-procedure that returns blood flow to heart by rerouting it through a new artery or vein that is grafted around diseased sections, coronary artery disease-narrowing of the small blood vessels that supply blood and oxygen to the heart, congestive heart failure-blood moves through the heart and body at a slower rate, and pressure in the heart increases. Shortness of Breath - SOB, Orthopnea (worse when lying flat), Paroxysmal Nocturnal Dyspnea - PND, Dyspnea on Exertion - DOE, Quivering of Atria (top of heart) causing an irregularly irregular rhythm, Inflammation of the sac surrounding the heart causing chest pain, Inflammation of the sac surrounding the lungs causing pleuritic chest pain, Irritation of the ribs causing chest pain worsened by pressing on the sternum, Costochondritis - Irritation of the chest wall causing pain with palpation of the chest, Fluid collecting around the lungs causing SOB or CP, EKG for STEMI -or- Elevated Troponin for Non-STEMI. An 23-year-old female is brought in by EMS for a motor vehicle crash. What do you need to make sure to document for every admitted patient? Costo-Vertebral Angle tenderness; flank tenderness - tenderness over kidneys, Alert and Oriented to Person, Place, and Time. (select all that apply. What is the benign "touch" exam for the Cardiovascular system? (choose one. A patient has the following history: breast CA s/p chemoradiation therapy and mastectomy. What procedure would be used to diagnose Meningitis? If a doctor says "Lead one, Lead two, or Lead three" what do you write? What must you always pay special attention to for any complaints of CP or SOB for URI patients? Given the information, what might the most likely diagnoses' end up being for these patients? CHEST PAIN: "Worse with deep breaths" is a red flag for.. What are you looking for when double checking your chart? Known DVT, PMHx DVT or PE, FHx, recent surgery, cancer, A Fib, immobility, pregnancy, BCP, smoking. In that case, consent is precluded by clinical urgency. ESR- Erythrocyte Sedimentation Rate. What is the core measure for Abd pain - female patient? What condition is often confused with CVA symptoms? Match the details to the correct section of the chart. CHEST PAIN: "Pleuritic pain" is a red flag for.. What must you document for a "code exam"? What is the medical term for painful urination? What must you document to any caveat to the level 5 elements? What tests will almost always be placed for every adult patient complaining of chest pain? A 45 year old male presents to the ED with a ripping, tearing pain to his central chest radiating straight to his back with associated nausea that began 1 hour ago. What is the medical term for "Enlarged Tonsils"? All symptoms documented in the ROS are also documented in the HPI. PMHx and PSHx count as 1 element. A patient cut his left foot on a piece of glass two hours ago and is seen in the emergency department to have sutures placed. How is CHF (fluid traffic jam) diagnosed? A 45 year old male presents to the ED with a constant, ripping, tearing pain to his central chest radiating straight to his back with associated nausea that began 1 hour ago. How would you document GPA for a patient who has previously been pregnant four times in the past, has three children at home, and is NOT currently pregnant? What is the benign "no touch" exam for the eyes system? In a Differential (includes CBC), what does "high bands / band cells" tell us? What is the medical term for "low potassium"? Check in and Chief Complaint 2. Liquid consumed by mouth to treat an upset stomach. If you saw "RRR" written in the cardiac exam, what do you think it might mean?