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39 Cards in this Set
- Front
- Back
What are the five main parts to Ed Flow? |
Cheif Complaint (CC) -> Physician Assessment: The History and Physical -> Objective Orders -> Results and Medical Decision Making -> Disposition |
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Chief Complaint |
The reason the patient came to the ED |
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HPI |
History of Present Illness |
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H&P |
History and Physical Exam |
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DDx |
Differential Diagnosis |
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Differential Diagnosis? |
Possible diseases that could cause the symptoms |
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Three types of Disposition |
Admitted Transferred Discharged |
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Describe Triage |
Nurse takes Cheif Complaint, Vital Signs, determines level of Acuity |
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HR |
Heat Rate |
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RR |
Respiratory Rate |
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What are the two types of bed placement? |
Main, Fasttrack |
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Levels of Acuity range? |
5 (Low) to 1 (High) |
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What are the subjective and objective parts of the H&P? What is the other part of H&P? |
1. Subjective: HPI (History of Present Illness) and ROS (Review of Systems) which is a head to toe commentary 2. Objective: PE (Physical Examination) 3. Past History (Hx) includes PMHx, PSHx, FHx, and SHx. That's Past medical, Past surgical, Family, and Social |
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MDM |
Medical Decision Making |
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What can a scribe do? |
Document history etc Access lab results Access X-rays Locate PMHx Record physician's interpretations of X-ray/EKG |
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Charge Nurse |
Manages ED patient flow |
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Mid-Level Provider |
LNP or PA that works under supervision of physician to diagnose/treat pts. |
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ED Nurse |
Records histories, symptoms, moitors pt, starts IVs, medications, etc |
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RT |
Respiratory Therapist administers breathing treatments |
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ED Tech |
Helps nurse, assists with procedures |
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Unit Secretary |
Places orders, answers phone calls, pages specialists, organizes paperwork |
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Pain Vs Tenderness |
Pt's feeling vs Physician's assessment |
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Benign |
Nrml, nothing of concern |
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Distress |
The doctor's judgement of discomfort |
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Febrile |
Feverish state, concerning for infection |
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Acute |
New onset, likely concerning |
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Chronic |
Long-standing, not of direct concern |
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Baseline |
Individual's normal state of being |
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Auscultation |
Listening with a stethoscope |
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Palpation |
Act of pressing on an area |
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Inpatient |
Admitted to the hospital overnight |
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Outpatient |
Seen and sent home in the same day |
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Order of Documentation Template |
1. HPI 2. ROS 3. PHx 4. PE 5. ED Course 6. Disposition |
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What is the ED Course? |
Objective results from labs, along with re-evals, consults, post medication feelings |
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True allergy vs Adverse Reaction |
True allergy causes rash, itching, swelling, or difficulty breathing. |
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If information is from the pt, it belongs in the... |
HPI or ROS |
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If information is from the doctor's observation of the patient, it belongs in the... |
PE |
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If the information is from an objective study, it belongs in the... |
course (results) |
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If the information came to light after the initial H&P it belongs in the... |
course (re-evaluations, consults, events) |