Subjective vs. Objective
patient thoughts vs doctors findings
CC
Chief complaint
MDM
medical decision making
baseline
an individuals normal state of being
Auscultation
listening with a stethoscope
palpation
act of doctor pressing on an area
Charge nurse
manages ED patient flow
Mid level provider
PA, LNP
records medical histories, symptoms, monitors patient, start IVs, administer meds
ED nurse
ED tech
CNA, MA
ED flow
1) check in -->chief complaint-->differential dx
2) Triage--> physician assessment--> H&P
3) bed placement -->labs
4)Final diagnosis -->MDM
5) disposition
The name of our documentation system?
allscripts
Levels of acuity
5=medication refill
2= shortness of breath,chest pain
1=most urgent
Vital signs
HR, BP, RR, T, SaO2
antiemetics
stop vomiting
analgesics
pain reliever
vasodilators
open blood vessels
Documentation order
HPI
ROS
Past history (medical, social, family)
PE
ED course (objective lab results)
Disposition
High blood pressure
hypertension
HTN
hypertension
high cholesterol
hyperlipidemia
HLD
hyperlipidemia
Diabetes
DM
I only take pills for my diabetes
Non insulin dependent diabetes
NIDDM
Non insulin dependent diabetes "type 2
I take shots for my diabetes
insulin dependent diabetes mellitus "type 1
IDDM
insulin dependent diabetes mellitus
Heart disease
Coronary artery disease
Heart attack
myocardial infarction
heart failure
congestive heart failure
irregular heartbeat
atrial fibrillation
episodes of abnormally fast/racing heartbeat
supra ventricular tachycardia
SVT
supra ventricular tachycardia
blood clot in lungs
pulmonary embolism
what causes PE?
DVT
Reflux
Gastroesophageal reflux disease
biggest cause of pancreatitis
alcoholism
kidney infection
pyelonephritis
kidney stones
renal calculi
I'm on dialysis
Chronic renal failure, end stage renal disease
ESRD
end stage renal disease
CRF
Chronic renal failure
Enlarged prostate
benign prostate hypertrophy
BPH
benign prostate hypertrophy
Gravida
para
abortion
total births
live births
miscarriage/ abortion
*
twins count as 1
*
stroke
Ischemic cerebrovascular accident
mini-stroke
transient ischemic attack
brain bleed
hemorrhagic CVA
blood clot in my leg
lower extremity DVT
bulge in my aorta
abdominal aortic aneurysm
AAA
abdominal aortic aneurysm
bad blood flow to my legs
peripheral vascular disease
PVD
peripheral vascular disease
Numbness in my legs
peripheral neuropathy
bulging/herniated disc
degenerative disc disease
DDD
degenerative disc disease
OA
osteoarthritis
RA
rheumatoid arthritis
chronic joint pain
degenerative joint disease
DJD
degenerative joint disease
weak/fragile bones
osteoporosis
tonsils removed
tonsillectomy
adenoids removed
adenoidectomy
ear tubes
pressure equalizer tubes
PE
pressure equalizer tubes
heart bypass
Coronary artery bypass graft
how to diagnose a CAD
cardiac catheterization
balloon in heart
angioplasty
breast removal
mastectomy
hole in my neck
tracheostomy
part of my lung removed
partial lobectomy
appendix removed
appendectomy
gallbladder removed
cholecystectomy
hernia repair
herniorrhaphy
part of colon removed
partial colectomy
bag to collect stool
colostomy
spleen removed
splenectomy
stomach stapled
gastric bypass
kidney removed
nephrectomy
uterus removed
hysterectomy
ovary removed
oophorectomy
ovary and Fallopian tubes removed
saplingo-oophorectomy
tubes tied female
tubal ligation
tubes tied male
vasectomy
prostate removed
prostatectomy
unterine product removed
dilation and curettage
D&C
dilation and curettage
neck artery cleaned
carotid endarterectomy
brain surgery
craniotomy
VP
ventriculoperitioneal shunt
PICC line
peripherally inserted central catheter (long term IV access)
clot filter lower abdomen
IVC filter , catches clots preventing PE
clot filter leg
Greenfield filter
AKA
above knee amputation
BKA
below knee amputation
joint repair
arthroplasty
metal plates/pins
hardware
neck fused
cervical spinal fusion
back fused
lumbar spinal fusion
ORIF
open reduction with internal fixation (hip surgery)