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