ScribeAmerica course 1 review
Walk in - Triage - Bed - Physician Assessment - Lab/Rad/Meds - Results - MDM - Diagnosis - Consults - Disposition
What are the 5 vital signs?
Blood Pressure, Pulse, Respiratory Rate, Temperature, Oxygen Saturation
The HPI and ROS are what type of information?
The Physical Exam is what type of information?
While evaluating a patient complaining of chest pain, your physician tells you that the heart sounds are normal. Would you document it in the HPI, ROS, or PE?
Would you be contradicting yourself if you wrote "The patient had abdominal pain" in the HPI, but then later in the physical exam documented "The abdomen is non-tender". Why or why not?
No, because the patient stating they have abdominal pain is a subjective complaint. A non-tender abdomen is an objective finding.
What is the difference between the HPI and ROS?
a. HPI is a story about the chief complaint and its associated symptoms
b. ROS is a checklist of symptoms. It includes the chief complaint, associated symptoms, and all other complaints the patient may have.
What does disposition (dispo) mean?
The patient's destination after they leave the ED. Have the patient leave the ED either by: admit, discharge or transfer.
What sub categories are included within the Past History section of the template?
a. PMHx: Past Medical History (HTN, HLD, CAD, DM...)
b. PSHx: Past Surgical History (Appy, Chole, T&A....)
c. FHx: Family History (Hx of CAD less than 55 y/o)
d. SHx: Social History (ETOH, smoking, drugs...)
What is the abbreviation for cardiac bypass?
CABG - Coronary Artery Bypass Graft
What is the abbreviation for high blood pressure?
HTN - Hypertension
What is the medical term for acid reflux?
GERD - Gastro Esophageal Reflux Disease
What is the medical term for stroke?
CVA - Cerebral Vascular Accident
What is the term for gallbladder removal?
What does NKDA stand for?
No Known Drug Allergy
What is the medical term for redness?
What is the medical term for bruising?
If the doctor says the exam was "benign", what does that mean?
Normal- Nothing of concern