Ed Scribe - Final Exam

Medical Decision Making (MDM) - Answer- The physician's thought process Pain vs. Tenderness - Answer- Patient's feeling vs. physician's assessment What does distress mean? - Answer- The doctor's judgment of discomfort Baseline - Answer- An individual's normal state of being What does Auscultation mean? - Answer- Listening with a stethoscope Palpation - Answer- The act of pressing on an area by the doctor Inpatient - Answer- Admitted to the hospital overnight Outpatient - Answer- Seen and sent home the same day What is the ED flow (overview)? - Answer- 1. Check in and Chief Complaint 2. Physician assessment 3. Objective orders and results 4. Medical Decision Making 5. Disposition What is the ED flow before orders are made? - Answer- 1. Arrival 2. Triage 3. Vital Signs / Bed Placement 4. Nurse Assessment 5. HPI, ROS, Hx, PE What is the ED flow after orders are made? - Answer- 1. Differential Dx 2. Physician orders labs, imaging, procedures, medications 3. Results and ED course 4. Final Dx 5. Disposition What is the general documentation template? - Answer- HPI ROS PHx PE ED course Disposition Thyroid problem means.. - Answer- Usually Hypothyroidism, sometimes hyperthyroidism "I only take pills for my diabetes" means.. - Answer- Non-Insulin Dependent Diabetes Mellitus - NIDDM "I take shots (insulin) for my diabetes" means.. - Answer- Insulin Dependent Diabetes Mellitus - IDDM Heart disease means.. - Answer- Usually Coronary Artery Disease - CAD Heart attack means.. - Answer- Myocardial Infarction - MI and CAD