Part 1: Scribe America Pre-Clinical Training Day 1: Emergency Department Flow

Front 1

What are the five main parts to Ed Flow?

Back 1

Cheif Complaint (CC) -> Physician Assessment: The History and Physical -> Objective Orders -> Results and Medical Decision Making -> Disposition

Front 2

Chief Complaint

Back 2

The reason the patient came to the ED

Front 3

HPI

Back 3

History of Present Illness

Front 4

H&P

Back 4

History and Physical Exam

Front 5

DDx

Back 5

Differential Diagnosis

Front 6

Differential Diagnosis?

Back 6

Possible diseases that could cause the symptoms

Front 7

Three types of Disposition

Back 7

Admitted

Transferred

Discharged

Front 8

Describe Triage

Back 8

Nurse takes Cheif Complaint, Vital Signs, determines level of Acuity

Front 9

HR

Back 9

Heat Rate

Front 10

RR

Back 10

Respiratory Rate

Front 11

What are the two types of bed placement?

Back 11

Main, Fasttrack

Front 12

Levels of Acuity range?

Back 12

5 (Low) to 1 (High)

Front 13

What are the subjective and objective parts of the H&P? What is the other part of H&P?

Back 13

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

Front 14

MDM

Back 14

Medical Decision Making

Front 15

What can a scribe do?

Back 15

Document history etc

Access lab results

Access X-rays

Locate PMHx

Record physician's interpretations of X-ray/EKG

Front 16

Charge Nurse

Back 16

Manages ED patient flow

Front 17

Mid-Level Provider

Back 17

LNP or PA that works under supervision of physician to diagnose/treat pts.

Front 18

ED Nurse

Back 18

Records histories, symptoms, moitors pt, starts IVs, medications, etc

Front 19

RT

Back 19

Respiratory Therapist administers breathing treatments

Front 20

ED Tech

Back 20

Helps nurse, assists with procedures

Front 21

Unit Secretary

Back 21

Places orders, answers phone calls, pages specialists, organizes paperwork

Front 22

Pain Vs Tenderness

Back 22

Pt's feeling vs Physician's assessment

Front 23

Benign

Back 23

Nrml, nothing of concern

Front 24

Distress

Back 24

The doctor's judgement of discomfort

Front 25

Febrile

Back 25

Feverish state, concerning for infection

Front 26

Acute

Back 26

New onset, likely concerning

Front 27

Chronic

Back 27

Long-standing, not of direct concern

Front 28

Baseline

Back 28

Individual's normal state of being

Front 29

Auscultation

Back 29

Listening with a stethoscope

Front 30

Palpation

Back 30

Act of pressing on an area

Front 31

Inpatient

Back 31

Admitted to the hospital overnight

Front 32

Outpatient

Back 32

Seen and sent home in the same day

Front 33

Order of Documentation Template

Back 33

1. HPI

2. ROS

3. PHx

4. PE

5. ED Course

6. Disposition

Front 34

What is the ED Course?

Back 34

Objective results from labs, along with re-evals, consults, post medication feelings

Front 35

True allergy vs Adverse Reaction

Back 35

True allergy causes rash, itching, swelling, or difficulty breathing.

Front 36

If information is from the pt, it belongs in the...

Back 36

HPI or ROS

Front 37

If information is from the doctor's observation of the patient, it belongs in the...

Back 37

PE

Front 38

If the information is from an objective study, it belongs in the...

Back 38

course (results)

Front 39

If the information came to light after the initial H&P it belongs in the...

Back 39

course (re-evaluations, consults, events)