Scribe Training 1

Front 1

Goals of a Scribe

Back 1

1). Perform rapid, accurate, and complete medical-lefal documentation for providers
2) Increase the efficiency of the provider

Front 2

ED FLOW Overview

Back 2

1. Patient comes to clinic with Chief complaint
2. Physician Assessment:
HPI, PE, DDx
3. Physician Orders
4. Medical Decision Making (MDM)
5. Disposition
a. Discharge
b. Admit

Front 3

Chief complaint

Back 3

What the pt says is wrong with them coming into the ER

Front 4

Physician's assessment includes what 3 things

Back 4

1. HPI
2. PE
3. DDx

Front 5

HPI

Back 5

History of Present Illness - Initial subjective complaints

Front 6

PE

Back 6

Physical Exam - Initial objective facts

Front 7

DDx

Back 7

Differential Diagnoses - A list of possible final diagnoses

Front 8

Examples of Physician orders

Back 8

lab tests, x-ray, CTs

Front 9

What does Discharge involve?

Back 9

Giving discharge (DC) instructions; and discussig follow-up.

Front 10

DETAILED ED FLOW: What are the 2 ways a pt can enter?

Back 10

Walk-in or EMS

Front 11

DETAILED ED FLOW: What's the 2nd step after pt comes in?

Back 11

Triage

Front 12

Triage involves?

Back 12

1. Chief complaint
2. Vital signs
3. Level of acuity

Front 13

What are the 5 vital signs?

Back 13

Heart rate
Blood Pressure
Respiration Rate
Temperature
O2 Saturation

Front 14

DETAILED ED FLOW: 3rd Step

Back 14

Bed Placement

Front 15

DETAILED ED FLOW: 4th step

Back 15

Nurse Assessment

Front 16

Nurse Assessment involves

Back 16

1. Confirming chief complaint
2. Reviewing allergies
3. Brief past Medical History

Front 17

DETAILED ED FLOW: 5th step

Back 17

History & Physcial ( H&P)

Front 18

3 parts of H & P

Back 18

1. Subjective
2. Past History
3. Objective

Front 19

SUBJECTIVE part of H&P

Back 19

Includes HPI and ROS

Front 20

Past History (Hx)

Back 20

PMHx, PSHx
(Past Med & Surgical History)
FHx, SHx
(Family & Social History)

Front 21

Objective

Back 21

PE - Physical Examination

Front 22

In general, "SUBJECTIVE" is?

Back 22

What the patient says

Front 23

IN general, "OBJECTIVE" is?

Back 23

Wha the doc says

Front 24

DETAILED ED FLOW:
After H&P is?

Back 24

physician orders

Front 25

After physician orders is?

Back 25

Differential Dx

Front 26

DDx

Back 26

Based on the H&P. list generated of things causing the pt's subjective symptoms. Doc places "orders" to rule out each differential.

Front 27

Different types of Phys orders?

Back 27

Lab studies
Radiology studies
Procedures
Medications

Front 28

Names some lab studies.

Back 28

Blood work
Microscopy
Cultures

Front 29

Radiology studies

Back 29

X-ray, CT, Ultrasound

Front 30

Name some Procedures.

Back 30

Sutures, Joint Reduction, Splints

Front 31

Medications

Back 31

Antiemetics
Analgesics
Vasodilators

Front 32

ED Course

Back 32

Reviewing orders' results.
Re-evaluating patient.
Consulting with specialists.

Front 33

Final Dx

Back 33

From the MDM the doc reviews specific results that can rule out DDx to reach the Final Dx.

Front 34

Disposition involves?

Back 34

Discharge home
Admit for further care
Transfer to another facility

Front 35

People in the ED

Back 35

Charge Nurse
MLP
ED Nurse
Respiratory Therapist
ED Tech
Unit Secretary

Front 36

Charge nurse

Back 36

Manages the ED patient flow

Front 37

MLP

Back 37

NP or PA working under supervision of a doc to diagnose and treat patients

Front 38

ED Nurse

Back 38

Records medical histories/symptoms, monitors the patient, starts IVs, administers medications, and assists with procedures

Front 39

Respiratory Therapist (RT)

Back 39

Administers "breathing treatments" and assists with managing a patient's airway.

Front 40

ED Tech

Back 40

Helps the nurse and assists with procedures

Front 41

Unit Secretary

Back 41

Places physician's orders, answers phone calls, pages other specialists/doctors, and organizes the patient's paperwork.

Front 42

Subjective vs. Objective

Back 42

Feeling vs. Fact

Front 43

Differential Dx

Back 43

list of possible dx to be "ruled out"

Front 44

Benign

Back 44

Normal, nothing of concern

Front 45

NAD

Back 45

No acute disease or no acute distress

Front 46

Febrile

Back 46

the state of having a fever, concerning for infection

Front 47

Acute

Back 47

New onset, likely concerning

Front 48

Chronic

Back 48

Long-standing, not of direct concern

Front 49

Baseline

Back 49

An individual's normal state of being

Front 50

STEMI

Back 50

Active heart attack

Front 51

Documentation system types

Back 51

TAPS, Epic, Cerner, Ibex, PICIS, Meditech, EPOWERdoc, T-system, E-Bart, EDIS, McKesson, Lynx, Allscripts, etc.

Front 52

General Template: 2 major parts (from top down)

Back 52

Subjective Complaints
Objective Evaluation

Front 53

General Template: Subjective Complaints include?

Back 53

HPI
ROS

Front 54

General Template:
After Subj Complaints section?

Back 54

Past History

Front 55

General Template:
Objective Evaluation

Back 55

Physical Examination
ED Course

Front 56

General Template: Last portion

Back 56

Disposition

Front 57

Common PMHx: General

Back 57

Hypertension (HTN)
Hyperlipidemia (High Cholest)
Cancer (CA)
Diabetes Mellitus (DM, IDDM, NIDDM)

Front 58

Common PMHx: Cardiac

Back 58

Myocardial Infarction (MI)
Coronary Artery Disease (CAD)
Congestive Heart Failure (CHF)
Atrial Fibrillation (AFib)

Front 59

Common PMHx: Pulmonary

Back 59

Pulmonary Embolism (PE)
Pneumonia (PNA)
Chronic Obstructive Pulmonary Disease (COPD)
Asthma

Front 60

Comon PMHx: Abdominal

Back 60

- Gastro Esophageal Reflux Disease (GERD)
- Abdominal Aortic Aneurysm (AAA)
- Pancreatitis
-Hepatitis (Hep B, Hep C)
- Diverticulitis

Front 61

Common PMHx: GU

Back 61

- Urinary Tract Infection (UTI)
- Kidney Stones
- Chronic Renal Failure (CRF)

Front 62

Common PMHx: Neuro

Back 62

- Cerebral Vascular accident (CVA)
- Transient Ischemic Attack (TIA)
- Epilepsy/Seizure (Sz)

Front 63

Common PMHx: Other

Back 63

-Deep Venous Thrombosis (DVT)
- Methicillin Resistant Staphylococcus Aureus (MRSA)
-Rheumatoid Arthritis (RA)
- Chronic Back Pain (CBP)/ Sciatica
- Osteoporosis
- Degenerative Joint Disease (DJD)
- Degenerative Disc Disease (DDD)

Front 64

Common PSHx: ENT

Back 64

Tonsillectomy/Adenoidectomy
Myringotomy/ PE Tubes

Front 65

Common PSHx: Abdominal

Back 65

-Appendectomy
-Herniorrhaphy

Front 66

Common PSHx: Ortho

Back 66

-Above the knee amp (AKA)
-BKA
- Hip Arthoplasty

Front 67

Common PSHx: Neuro

Back 67

Craniatomy
AV shunt

Front 68

Common PSHx: Other

Back 68

-Exploratory Laproscopy (ExLap)

Front 69

Common FHx: General

Back 69

HTN, DM, CA

Front 70

Common FHx: Cardiac

Back 70

CAD/MI, at less than 55 yo

Front 71

Common FHx: Pulmonary

Back 71

PE
Asthma

Front 72

Common FHx: Abdominal

Back 72

Cholecystitis

Front 73

Common FHx: GU

Back 73

Kidney Stones

Front 74

Common FHx: Neuro

Back 74

CVA, Aneurysm, Seizures

Front 75

Common FHx: Other

Back 75

Sickle-cell, DVT

Front 76

SHx: ETOH frequency

Back 76

Daily
Occasionally
Neverl

Front 77

SHx: Tobacco

Back 77

-- Current (#ppd, #of years)
-- Former (year quit)
-- Never

Front 78

SHx: Drugs

Back 78

- Type of drug abused (opiates, cocaine, methamphetamines)
- Method of abuse (oral, IV, inhaled)
- Date of last use

Front 79

SHx: Occupation

Back 79

If the doc asks, be sure to doc it

Front 80

SHx: Living circumstances

Back 80

-Alone
- With Fam/Friends
- Homeless
- Nursing Home/Assisted Living
- Hospice

Front 81

Ecchymosis

Back 81

Bruising

Front 82

5 Vital signs

Back 82

HR, Temp, BP, Respiration rate, O2 Saturation

Front 83

NKDA

Back 83

No Known Drug Allergies

Front 84

DVT

Back 84

Deep Venous Thrombosis

Front 85

Passing out or fainting

Back 85

Syncope

Front 86

Sweating

Back 86

Diaphoresis