Medical Scribe Latest Update Graded A+

Medical Scribe Latest Update Graded A+ CAD coronary artery disease HTN hypertension DM diabetes mellitus MI myocardial infarction CHF congestive heart failure AFIB atrial fibrillation PE pulmonary embolism DVT deep venous thrombosis BKA below knee amputation PTX pneumothorax COPD chronic obstructive pulmonary disease PNA pneumonia GERD gastroesophageal reflux disease CVA (stroke) cerebrovascular accident TIA transient ischemic attack URI upper respiratory infection UTI urinary tract infection AAA abdominal aortic aeurysm SBO small bowel obstruction DNR do not resuscitate CP chest pain SOB shortness of breath N/V/D nausea/vomitting/diarrhea HA headache DOE dyspnea on exertion BM bowel movement AMS altered mental status LOC loss/level of consciousness MVA motor vehicle accident OD overdose CC chief complaint c/o complains of h/o history of a with line over it before c with line over it with s with line over it without s/p status post delta change EMS emergency medical services PTA prior to arrival EOMI extra ocular movements intact PERRL pupils equal round and reactive to light CVA costovertebral angle tenderness DPP dorsalis pedis pulse A & O alert and oriented NTG nitroglycerin ASA aspirin NSAID non steroidal anti-inflammatory drug O2 2L NC oxygen 2 liters nasal cannula PCN penicillin NSR normal sinus rhythm RBBB right bundle branch block PVC premature ventricular contractions ST increase ST elevation LAD left axis deviation H&H hemoglobin and hematocrit Trop troponin CXR chest x-ray US ultrasound CT A/P cat scan abdomen pelvis Appendix removal appendectomy Gall bladder removal cholecystectomy Breast removal mastectomy Tubes tied bilateral tubal ligation uterus removal hysterectomy open heart surgery coronary artery bypass graft carotid artery cleaning carotid endarterectomy kidney removal nephrectomy partial colon resection partial colectomy stomach stapled gastric bypass slow heart rate bradycardia bruising ecchymosis fast breathing rate tachypnea pain with urinating dysuria pass-out syncope swelling edema throat redness pharyngeal erythema black tarry stools melena runny nose rhinorrhea muscle aches myalgias acute blockage of an artery that provides blood to the brain CVA translocation of a thrombus leading to dyspnea and hypoxia PE inflammation of a small vermiform appendage prone to rupture; this disease is the leading concern for any lower abdominal pain appendicitis electrical irregularity of the heart with concern about developing RVR AFIB ischemia and infarct of the anterolateral myocardium STEMI Pneumothorax (disease work-up) CXR Right femur fracture (disease work-up) right hip/ thigh xray PE (disease work-up) CTA or VQ scan Cholelithiasis (gallstones) (disease work-up) RUQ US CHF (disease work-up) CXR or Elevated BNP Hemorrhagic CVA (disease work-up) CT head or lumbar puncture Appendicitis (disease work-up) CT A/P with PO contrast Meningitis (disease work-up) Lumbar puncture AFIB (disease work-up) EKG Pancreatitis (disease work-up) Elevated lipase Who is the intended audience of an HPI? Give an example of someone other than your physician who may read it after the patient has been dispositioned. Hospitalist, specialist, medical coders, lawyers, PCP.... What is the central difference between the HPI and ROS? HPI is the story of the chief complaint ROS is a head to toe review ( a checklist of positive and negatives) What are 4 types of focal neurological deficits? 1.) Changes in speech 2.) Changes in vision 3.) One sided motor weakness 4.) One sided numbness or tingling A female patient has been pregnant four times in the past, is currently pregnant, and has two children at home. Calculate the G, P, and Ab G: 5 P: 2 A: 2 Please list three very important cardiac risk factors? CAD Family HX or CAD < 55 Y/O HTN DM Smoking Hyperlipidemia If a patient came to the ED complaining of a productive cough and notes that they also have a fever, would you document the "fever" in the HPI or the ROS? Why? HPI pertinent to CC You are evaluating a patient complaining of exacerbated back pain for two days. He notes that he has also had a runny nose for a week. Would you document the "runny nose" in the HPI or ROS? Why? ROS, not pertinent to CC What are four things that you should document in the HPI for any patient presenting to the ED after a syncopal episode? 1.) Symptoms before event 2.) Symptoms during event 3.) Symptoms after event 4.) How they feel currently The physician checks the patient's pulses at the right wrist, the top of the right foot, and the left neck. The doctor states " The pulses are fine". What do you right on the chart? Right radial +2 Right DP +2 Left carotid +2 The physician states "there is no rebound, no guarding". What part of the body are they examining? Abdomen Can you document both "clear breath sounds bilaterally" and "rhonchi in the right base"? Why or why not? No, they contradict each other Your physician interprets a patient's EKG prior to performing the physical exam: they tell you "The EKG shows AFIB at a rate of 90 beats per minute." Later in the patient's room, during auscultation of the heart, what type of rhythm will the doctor certainly hear and verbalize to you? Irregularly irregular rhythm What part of the physical exam would contain both "pronator drift" and "CN II-XII intact"? Neurological How many body system would you need to document for a "Level 5" ROS 10 List 5 of the coding "elements" of an HPI 1.) Location 2.) Severity 3.) Quality 4.) Timing 5.) Onset 6.) Associated symptoms 7.) Modifying factors 8.) Context True/False Is it acceptable to look up your own medical information while working in the ED FALSE True/False While working in the ED you can look up your little brother's medical information because he was recently seen in the ED last week. FALSE True/False Brittany Spears is checked in as a patient in the ER. Is it OK to open her chart as long as you don't tell anybody about what you read? FALSE What is Protected Health Information (PHI)? Give an example. Any information that can identify and pertains to a patient, IE: name, DOB, CC, results You are working a shift with Dr. Murphy: can you access any PHI for another patient in the ED that is not being cared for by Dr. Murphy? No Describe what you would do if you saw another scribe helping to lift a patient off a backboard and onto a stretcher. Inform that scribe politely that it is not within the scope of our profession to assist with this. Get someone else to help, and let the chief scribe know. For each of these chief complaints there are two major disease processes that can quickly end a patient's life. What are they? Chest pain: MI, Dissection Lower Abd. pain: Appendicitis, AAA, Ectopic, GI bleed Dyspnea: PE, PTX