Classroom Training 1

Leg amputated

- Above Knee Amputation (AKA) - Below Knee Amputation (BKA)

Physician: History and Physical

- History of Present Illness (HPI) - story about CC - Review of Systems (ROS) +/- checklist - Past History - Physical Exam (PE) - DDx (differential diagnoses) - ONLY for diagnostic visits (list of possible Dx that could be causing patient's complaints)

Check out

- Home v. sent to ED - Pt edu prov - Pt often stop at front desk on way out to sched next appt

Scribes can

-Document the history, physical exam, results, procedures, assessment, and plan -Access and document laboratory results and radiology findings -Locate and obtain PMHx, previous charts, past results, and recent studies -Record physician interpretations of x-rays and EKGs

Scribe Perks

-Learn about medicine (diseases, symptoms, diagnoses, treatments, terminology, etc) -Document like a clinician - gain first hand experience - build lasting relationships - opportunity for letters of rec - great resume builder - lots of options for career advancement

Scribes cannot

-touch patients -write orders or prescriptions -give verbal orders -partake in any activity that may affect patient health or outcome -sign or authenticate any chart or record -handle bodily fluids or specimens

PMHx: Common Past Medical History

1. Layman's term: what pt call disease 2. Medical term: actual term 3. Abbrev

Adenoids removed

Adenoidectomy

SHx: Social History

Alcohol use, tobacco use/vaping, drug use, occupation environment/stress, living environment

FHx: Family History

Any medical conditions in pt's blood relatives - younger age of onset (under 55) means higher genetic risk: less due to environment

"Balloon in my heart"

Balloon Angioplasty -> PMHx CAD

Enlarged prostrate

Benign prostatic hypertrophy (BPH)

Cancer (of the _)

Cancer or Carcinoma (CA) of _

Stroke

Cerebrovascular Accident (CVA)

Order of Patient Processing

Check in and CC History and Physical Orders and Results Assessment and Plan Check Out

Health Management

Check-up, CC: Routine physical or management of chronic problem(s), goal is preventative care and/or assessing progress of chronic problems

"Chemo"

Chemotherapy

"I'm on dialysis"

Chronic Kidney Disease (CKD) on dialysis

Heart bypass or Open heart surgery

Coronary Artery Bypass Graft (CABG) "cabbage" --> PMHx CAD

"Stents in my heart"

Coronary Stents -> PMHx CAD

Tenderness

Doctor's finding of reproducible pain (objective)

EMR/EHR

Electronic Medical Record/Electronic Health Record

Ulcers

Gastric Ulcer or Peptic Ulcer Disease (PUD)

Reflux

Gastroesophageal Reflux Disease (GERD)

Brain Bleed

Hemorrhagic CVA

It's gone

In remission

Irritable bowel

Irritable Bowel Syndrome (IBS)

"Blood clot in brain"

Ischemic CVA

Orders and Results

Lab Studies: Imaging: Procedures:

Chronic

Long-standing, not of direct concern

New patients (30-45 minutes)

Never been seen at clinic/> 3 years, no previous records, longer visit (need information so tests, check-up), detailed chart

Acute

New onset, likely concerning

Diagnostic Visit

New problem, CC: New symptom, goal to determined cause of prob and appr treatment

Patient arrives in Clinic and assigned a room

Nurse or MA Assessment - Diagnostic v HM - Vital Signs - HR - BP

pt has BKA listed in PSHx, where else might see?

PE

*Common Error/Tip

PE and lab/rad findings in Objective, not in like HPI

part of my colon removed

Partial colectomy

Part of my lung removed

Partial lobectomy

Established patient (15-30 minutes)

Patient seen at clinic within last 3 years, previous records available, shorter visit, concise chart

Pain

Patient's feeling of discomfort (subjective)

"Bad blood flow in my legs"

Peripheral Vascular Disease (PVD)

*Catch name of condition, but don't know how to spell...what to do?

Phonetically spell on google - if don't catch/can't spell, follow up with provider afterwards

Assessment and Plan

Physician: Assessment - list of current diagnoses - summary of visit Physician: Plan - Instructions for lifestyle changes - Medications - Follow-up

Before entering room (H and P)

Provider (and scribe usually) review pt medical records: - assessment + plan from previous visit - labs and/or imaging results

PSHx: (past surgical history)

Pt typically describes what was done and will need to recognize and spell name of procedure

Kidney Infection

Pyelonephritis (Pyelo) (travelled to kidneys)

"Radiation"

Radiation Therapy

Home Meds and Allergies

Reviewed by Nurse and MA before - catch if any specific home meds are part of "story" that brough pt to clinic (e.g. Rx refill) - pay attention to any allergies reviewed by the doctor

True allergy

SSRI (swelling, shortness of breath, rash, itching)

Pt says - Heart Disease - Heart Attack - Heart failure - Irregular Heartbeat - Emphysema or Chronic Bronchitis - Blood clot in lung - Pneumonia or lung infection

Scribe writes - Usually Coronary Artery Disease (CAD) - Myocardial Infarction (MI) and CAD - Congestive Heart Failure (CHF) - heart inefficient at circulating blood - Arrythmia - Chronic Obstructive Pulmonary Disease (COPD) - Pulmonary Embolism (PE) - Pneumonia (PNA)

Patient says - high blood pressure - high cholesterol - diabetes - "only take pills for my diabetes" (Type 2) - "take insulin shots" (Type 1 or Type 2)

Scribe writes... - Hypertension (HTN) - Hyperlipidemia (HLD) -Diabetes Mellitus (Type 1 or 2?) - Non Insulin Dependent Diabetes Mellitus (NIDDM) - Insulin Dependent Diabetes Mellitus (IDDM)

"They cut it out"

Status-post surgical resection

SOAP (Subjective, Objective, Assessment, Plan)

Subjective: -HPI (history of present illness: story of CC) -ROS (review of systems: head-to-toe list of positive and negatives) Past History (Medical, Surgical, Social, Family) Objective: - PE - Orders and Results Assessment (Current Diagnoses) Plan (treatment plan and follow up)

"Mini stroke"

Transient Ischemic Attack (TIA) - symptoms resolving within a few hours, functionality coming back

Bladder Infection

Urinary Tract Infection (UTI) (in lower gu area)

"Spread to my"

With metastasis to the _

PMHx of chronic alcoholism

also goes in SHx

"Bulge in my aorta"

aortic aneurysm

Appendix removed

appendectomy

Joint Repair

arthroplasty

"Neck arteries cleaned"

carotid endarterectomy

gallblader removed

cholecystectomy

Blood clot in my leg

deep vein thrombosis (DVT)

Objective

factual finding from the provider

CABG

grafting an artery to work as a detour for blood around a blockage

uterus removed

hysterectomy

"Adverse reaction"

if doesn't meet SSRI (e.g. nausea)

Breast Removal

mastectomy

kidney removed

nephrectomy

ovary removed

oophorectomy

Subjective

pt's experience/feeling

spleen removed

splenectomy

-otomy

surgical created opening

-plasty

surgical repair

Chief Complaint (CC)

the main reason for the patient's visit

Tonsils removed

tonsillectomy