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What are the 3 types of dispositions? Discharge, Admit, Transfer What does HPI stand for? history of present illness What does ROS stand for? review of systems The HPI and ROS are considered what type of information? subjective The physical exam is what type of information? objective If a physician told you a patient's abdomen was non tender, where would you document this? PE What section focuses directly on the chief complaint? HPI If someone has a hx of CABG or MI, what is something you can also always document in the PMHx section of the chart? CAD

Name an example of something you may write in the Social Hx portion of the chart. smokes 1 pack/day Name an example of something you may write in the Family Hx portion of the chart. Mother had Hx of CAD at age 46 What are the abbreviations for the following past medical history terms? Hypertension Stroke Diabetes Heart Attack High Cholesterol HTN CVA (cerebrovascular accident) DM MI HLD What are the medical terms for the following past surgical terms? Removal of the appendix Removal of the gallbladder Removal of the uterus Removal of a fallopian tube Removal of the tonsils Removal of the breast appendectomy cholecystectomy hysterectomy Salpingo-oophorectomy tonsillectomy mastectomy

What are the five vital signs? Blood pressure (BP), heart rate (HR), oxygen saturation (SaO2), respiratory rate (RR), temperature (C or F) What does NKDA stand for? no known drug allergies What does LNMP stand for? Last Normal Menstrual Period If the doctor said the exam was "benign", what does this mean? this means that the exam was normal and of no concern Explain acute vs chronic. acute: serious, new condition, that could potentially be life-threatening chronic: not of much concern, long-lasting condition, typically not a death threat What are the medical terms for the following pathophysiology abbreviations? CAD AAA COPD PNA URI coronary artery disease abdominal aortic aneurysm chronic obstructive pulmonary disease pneumonia upper respiratory disease How are the following diseases diagnosed? -CHF (two answers)

-PE (three answers) -Cholecystitis -Pancreatitis -Appendicitis -Hemorrhagic CVA (two answers) -DVT -chest x-ray, bnp (b-type natriuretic peptide) -CT chest with IV contrast (CTA chest), VQ scan, D-dimer -abdominal ultrasound (US) of RUQ -elevated lipase lab test -CT AP w/ PO -CTA w/ IV contrast, LP (lumbar puncture) -ultrasound (US) What are the two types of heart attacks and how are they diagnosed? STEMI (ST elevation myocardial infarction) and NSTEMI (non ST elevation myocardial infarction) STEMI: EKG NSTEMI: troponin What are three cardiac risk factors? HTN, DM, HLD, CAD, Smoking, FHx CAD < 55 y/o What are four associated symptoms of an MI other than CP? (Hint: catch phrase) Chest pressure with diaphoresis, N/V (nausea and vomiting), and SOB What are three symptoms a patient with an Ischemic CVA might present with? Unilateral focal neurological deficits: One-sided weakness, one-sided numbness or changes in speech/vision What are the only three symptoms of a true allergic reaction? SOB (difficulty breathing), rash, itching/swelling What heart rhythm would a physician hear if the patient were in atrial fibrillation and how is this disease diagnosed? an irregularly irregular rhythm, this is diagnosed by and EKG What physical exam finding is associated with asthma? wheezes (while inspiring or expiring)

How is altered mental status different from a focal neurological deficit? AMS is very different than a focal neurological deficit. AMS is generalized and is typically caused by things that affect the whole brain (drugs, low blood sugar). Focal neurological deficits are localized weakness/numbness in one specific area, corresponding with damage at one specific site in the brain. The most common cause of AMS for patients without a Hx of dementia is from infection, most often caused by a UTI. What is the major cause of AMS in the elderly? UTI Name one medication associated with seizures. Dilantin, Tegretol, Keppra, Depakote, Neurontin What question is every patient asked who comes in with a chief complaint of syncope? Document what happened prior, during, and after the syncopal episode, as well as how the patient currently feels What is the medication administered for CVAs and when is it used vs when would it not be indicated? Ischemic CVA: tPA or another anticoagulant (not used for a hemorrhagic CVA because it breaks down blood clots and if there is a brain bleed, this would not be helpful in this case) Hemorrhagic CVA: anticonvulsants What is "layman's name" for GERD? Acid Reflux/Heartburn What is the most common cause for seizures in children? fever In your own words, describe the significance of an HPI. The HPI is the beginning of every chart summarizing the reason for the visit and this describes the CC *The HPI should ONLY include information directly related to the CHIEF COMPLAINT and IMPORTANT CONTEXT for that patient. Name three people who will read the HPI other than the physician.

Nurses, Coders, and admitting doctors Name six elements of the HPI quality, location, timing, onset, duration, associated symptoms, severity, modifying factors, context How many elements of the HPI do you need to document for a complete chart? 4 elements True or False: The patient's entire ED visit is based on their answers to the questions asked during the HPI. true True or False: Accurate chronology is not important in an HPI. false- accurate chronology is very important What is the main difference between an HPI and an ROS? HPI contains the CC and anything directly related to why the patient is there, whereas the ROS is a checklist of symptoms that the patient does or does not have. How many elements of the ROS do you need to document for a complete chart? 10 elements List five body systems found in the ROS and provide two symptoms for each system. Genitourinary: dysuria, Frequency, urgency, Hematuria Neurological: HA, Syncope, Seizure, Numbness, Focal weakness Cardiovascular: CP, palpitations, leg swelling (edema) Gastrointestinal: Abdominal pain, N/V/D, Black or bloody stools Constitutional: Fever, weight loss, diaphoresis True or False: The symptoms listed in the ROS can contradict the symptoms discussed in the HPI. True - although not extremely common, the symptoms listed in the ROS can contradict the symptoms of the HPI How would you document the GPA for a patient who is currently pregnant, has been pregnant two times in the past, and has one child at home? 4/1/ What box would you check to communicate that the patient did not mention any other complaints other than those mentioned?

We do not mark a box at Sparrow for "all other symptoms must be negative" Write the meaning of the following physical exam abbreviations. NAD AT/NC PERRL EOMI TM RRR JVD TTP FROM CVA tenderness A&O SI/HI -no acute distress -atraumatic/normocephalic -pupils equal, round, reactive to light -extraocular movements intact -tympanic membrane -regular rate and rhythm -jugular vein distention -tenderness to palpation -full range of motion -costovertebral angle tenderness -alert and oriented -Suicidal and Homicidal ideations Answer the following questions by writing the condition or disease that is associated with each physical exam finding.

1. Scleral icterus
2. Fluorescein uptake
3. Bulging and erythematous TM
4. Dry mucous membranes
5. Tonsillar exudate
6. Sinus tenderness
7. Nuchal rigidity
8. Irregularly irregular
9. JVD
10. Wheezing
11. Pale conjunctiva

12. Rales
13. McBurney's Point Tenderness
14. Murphy's Sign
15. Hypoactive Bowel Sounds
16. Guaiac Positive (Heme +)
17. CVA tenderness
18. Urticaria
19. Fluctuance and Induration
20. Bilateral pitting pedal edema
21. Calf tenderness
22. Facial asymmetry
23. Unilateral weakness
24. liver failure
25. corneal abrasions or ulcerations
26. otitis media (ear infection)
27. dehydration
28. strep throat
29. sinusitis
30. meningitis
31. a-fib
32. CHF
33. asthma/COPD
34. anemia
35. CHF
36. appendicitis
37. cholecystitis
38. constipation
39. GI bleed
40. kidney stone
41. rash
42. abscess
43. CHF
44. DVT
45. Bell's palsy
46. ischemic CVA What do you write on the chart if doctor states, "The pulses are fine" after checking the patient's pulse near the .... Wrists

Heel Top of the foot Neck Pelvis region radial pulses 2+ bilaterally dorsalis pedis pulses 2+ bilaterally posterior tibial pulses 2+ bilaterally carotid pulses 2+ bilaterally femoral pulses 2+ bilaterally Which words do you think are synonyms with the word "red" erythematous, indurated What organ is in the following abdominal quadrant? RUQ RLQ LUQ LLQ gallbladder appendix pancreas large intestine What is the physician checking for when they hold their stethoscope to both sides of the patient's neck? a carotid bruit What is an extrasystole? extra beats What does an elevated White Blood Cell (WBC) count indicate? infection What does a low Hemoglobin and Hematocrit (H&H) indicate? anemia What is the term for high sodium levels called? hypernatremia What body organ do LFT's investigate?

liver function Name two of the LFTs? T bili AST ALT Alk Phos What labs show kidney function? creatinine, BUN Name three parts of the "Cardiac Order Set" CBC, BMP, Troponin, EKG, CXR What is the medical term for low potassium? hypokalemia How many tubes of CSF fluid are collected during a lumbar puncture? Why? 4 tubes are collected of CSF fluid during an LP because the first two are likely to be contaminated What does a positive HCG result indicate? pregnancy What is more accurate? Urine Dip -or- Urine Micro Urine Micro is much more accurate What are the three labs to monitor closely for efficiency? (Hint: "rate limiting steps") D-dimer Troponin Creatinine True or False: Cultures will never result in the same day they are ordered. True True or False: Emergency physicians are not able to interpret their own Xrays. True What is the name of the procedure used to treat an abscess? Incision and Drainage (I&D) What does NSR stand for as an EKG abbreviation?

normal sinus rhythm What would you write if the doctor said, "ST elevation noted in leads two, three, A-V- L, and V one through V three."? Acute ST elevation What procedure is performed when a joint is dislocated? joint reduction When might an ER doctor obtain a physician consult? Regarding admission, advice over treatment plan, inform primary physician of results, etc. In your own words, describe the significance of Critical Care this is the type of care that is administered for any patient that is at serious risk for major deterioration Name two procedures that would qualify for Critical Care. chest tube, intubation What is a normal INR for someone who is NOT on coumadin?

2.5 for someone is on coumadin What are the three major sites for central line placement? Internal Jugular Subclavian Femoral Name a common local anesthetic used for laceration repairs lidocaine What is the indication for a chest tube to be placed in a patient? PTX or hemothorax How do you know if a patient has a UTI on a urinalysis? WBC, Nitrite, or Bacteria True or False: The final diagnosis is the culmination of the entire ED workup. True

True or False: Each diagnosis becomes a permanent part of the patient's medical history true How many elements are required in the following sections to reach a "Level 5" chart? HPI ROS PMHx/PSHx,FHx, SHx Physical Exam 4 10 2 8 True or False: If any part of the patient care is not documented then the physician cannot legally be reimbursed for their time or expertise. true True or False: Your little brother was recently seen in the ED last week and had blood cultures taken. As a scribe, you can look up his results. false True or False: I can look up my own past medical records. false Give an example of PHI. Patient name, Geographic subdivisions, Telephone numbers, Email addresses, Fax Numbers, Health Plan beneficiary numbers, Social Security Numbers, Certificate/license numbers, Healthcare Record numbers, Account Numbers, Dates (except years), Any other Unique number, code, or characteristic that can be linked to an individual What word should you never document in a pediatric chart unless your provider specifically asks you to? lethargic What is the goal of a scribe? to decrease the number of down-coded charts What might a person with PNA complain of?

Productive cough and fever What lab order contains the H&H? CBC What does Creatinine measure? renal function What does a negative D-dimer mean? No evidence of PE What does a positive D-Dimer mean? Possible PE, must order a CTA Chest or VQ Scan What do "Coag" lab tests examine? Blood coagulation (how fast the blood clots) / Coumadin levels