Urgent Care Work Flow/More medical terminology (Day 1)
What is the hierarchy of urgent care overflow?
-Chief Complaint -Physician Assessment: The History of the Physical (H&P) -Objective Orders -Assessment and Plan -Disposition
If the info is from the patient where will it go on the chart?
-HPI or ROS
What is the general document template?
-History of patient illness (HPI): story and context and chief complaint -Review of Systems (ROS): head-to-toe list of positives and negatives -Past History (PMSHX, SHx, FHx): past diseases/surgeries, EtOH/Tobacco, FHx -Physical examination (PE): physicians objective findings -Assessment & Plan (A&P): evidence for a diagnosis and plan for treatment -Disposition: discharge instructions and follow-up
What are the various people in the UC?
-Receptionist -Mid-level provider: nurse practitioner, PA -Nurse: records medical histories, symptoms, monitors the patient, starts IVs, administers meds, and assists w/ procedures -Respiratory Therapist (RT): administers breathing treatments -Medical Assistant: helps the nurse and assists w/ procedures -Radiology Tech: assists w/ positioning and performing X-rays
What can scribes do?
-document the history, physcial exam, results, procedures, and physician consults -access and display x-rays for the physician to review -locate and obtain PMHx, previous charts, past results, and recent studies -Record physician interpretations of X-rays and ECGs
What is subjective vs objective?
-subjective: feeling -Objective: fact
What can scribes NOT do?
-touch patients -write orders or prescriptions -give verbal orders -sign or authenticate any chart or record -handle bodily fluids or specimens
Difference between true allergy and an adverse rxn
-true allergy causes a rash, itching, swelling, or difficulty breathing; otherwise it is an adverse rxn
Dialysis fistula
AV (arteriovenous) Fistula
Dialysis graft
AV graft
bulge in my aorta
Abdominal Aortic Aneurysm (AAA)
Leg amputated
Above Knee (AKA) Below knee (BKA)
Surgery for Afib
Afib s/p cardiac ablation
Balloon
Angioplasty---PMHx CAD
Appendix removed
Appendectomy
Joint repair
Arthroplasty
Irregular heart beat
Atrial Fibrillation (A-Fib)
Defibrillator
Automatic Implanted Cardiac Defibrillator (AICD)
Cancer
Cancer or Carcinoma (CA); brain, breast, lung, colon, prostate, ovarian, skin, bone, leukemia, or lymphoma
Heart Cath
Cardiac catheterization
Neck artery cleaned
Carotid Endarterectomy
stroke
Cerebrovascular Accident (CVA)
C-section
Cesarean section
Chemo
Chemotherapy
Gallbladder removed
Cholecystemocy
Low back pain
Chronic Low Back Pain
Emphysema/Chronic Bronchitis
Chronic Obstructive Pulmonary Disease (COPD)
I'm on dialysis
Chronic Renal Failure (CRF) on dialysis
Bag to collect stool
Colostomy
Heart failure
Congestive Heart Failure (CHF)
Heart bypass
Coronary Artery Bypass Graft (CABG)----PMHx CAD
Heart Disease
Coronary Artery Disease (CAD)
Stents
Coronary Stents---PMHx CAD
Brain surgery
Craniotomy (brian bleed vs brain CA)
Crohn's/UC
Crohn's Disease or Ulcerative Colitis
Bulging/herniated disc
Degenerative Disc Disease (DDD)
Joint pain (chronic)
Degenerative Joint Disease (DJD)
What is Disposition?
Discharged and sent home OR Transferred to another facility
What documentation system do we use?
Docutap
i drink a lot
EtOH abuse or alcoholism
Ulcer
Gastric Ulcer or Peptic Ulcer
Stomach stapled
Gastric bypass
Reflux
Gastroesophageal Reflux Disease (GERD)
Clot filter (leg)
Greenfield Filter
Murmur
Heart murmur
Hernia repair
Herniorrhaphy
High Cholesterol
Hyperlipidemia (HLD)
Uterus removed
Hysterectomy
Clot filter (lower abdomen)
IVC (inferior vena cava) Filter
If info comes to light after the initial H&P where does it go?
In the Assessment and Plan
If info is from an objective study where doe sit belong?
In the results
Irritable Bowel
Irritable Bowel Syndrome (IBS)
Breast removal
Mastectomy
If the patient only takes pills for their diabetes
NIDDM
If info is from the doctor's observation of the patient where does it go on the chart?
PE
Pacer
Pacemaker
Part of my colon removed
Partial colectomy
part of my lung removed
Partial lobectomy
bad blood flow to my legs
Peripheral Vascular Disease (PVD)
PICC line
Peripherally Inserted Central Catheter (PICC)
Port
Port-a-cath or Medi-port
Prostate removed
Prostatectomy (most often Trans-Urethral Removal of the Prostate (TURP)
Blood clot in lung
Pulmonary Embolism (PE)
kidney infection
Pyelonephritis (Pyelo)
Radiation
Radiation therapy
Kidney Stones
Renal calculi
Ovary and fallopian tubes removed
Salpingo-oophorectomy
Spleen removed
Splenectomy
Episodes of abnormally fast/racing heartbeat
Supraventricular Tachycardia (SVT)
Hole in my neck
Tracheostomy
Mini-stroke
Transient Ischemic Attack (TIA)
Tubes tied
Tubal ligation (female) Vasectomy (male)
bladder infection
Urinary tract infection
Thyroid problem
Usually Hypothyrodism but less commonly could be Hyperthyroidism
Arthritis
Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA)
Weak/fragile bones
Usually Osteoporosis
Who typically enters home medications into the system?
Usually the nurse or MA
Valve surgery
Valve repair or replacement (bovine vs mechanical)
Shunt
Ventriculoperitoneal (VP) shunt
Spread to my....
With metastases to the....
adenoids removed
adenoidectomy
What is antipyretic?
anti-fever medication
What is antimetics?
anti-nausea/vomiting medicaton
What is a analgesics?
anti-pain medicaiton
Enlarged Prostate
benign prostate hypertrophy (BPH)
Heart Attack
either MI or CAD
brain bleed
hemorrhagic CVA
What is the objective orders?
if the diagnosis is not obvious from the initial H&P, the provider may order specific lab or imaging tests to investigate each remaining differential diagnosis to determine if the disease is present
What is the physician assessment?
initial subjects complaints (HP) and objective facts (physical exam) -Differential diagnosis: (DDx) possible diseases that could cause the symptoms
Inpatient vs outpatient
inpatient is admitted to hospital overnight outpatient is in and out same day
blood clot in my leg
lower extremity DVT
ovary removed
oophorectomy
ear tubes
pressure equalizer (P.E.) Tubes
its gone
remission
Seizures
seizure disorder/epilepsy
they cut it out
status-post surgical resection
What is distress?
the doctor's judgement of discomfort
What is the chief complaint?
the main reason the person came in
What is the Assessment and Plan?
the physical exam and each objective result is reviewed to determine which differential diagnosis is most likely causing the patients symptoms and how it should be treated
tonsils removed
tonsilectomy
