The Basics
The main reason for the visit as expressed by the patient or representative.
What is the chief complaint?
This federal agency regulates prescriptions of certain types of drugs.
What is the DEA?
Under this button in the Epic chart, you will place in-house orders (orders given in the emergency department).
What is the Manage Orders button?
This is the "dot phrase" used to place a procedure note in the chart.
What is .PRLACERATION
If the patient has rales/crackles, rhronchi, or wheezes what needs to be changed in the Physical exam under "lungs/thorax."
What is "Normal breath sounds?"
This bolded element includes what the patient was exposed to, what they were doing, and where they were at when their symptom(s) onset.
What is context?
This is a safety precaution indicated in the name of a medication.
Ex: PredniSOLONE
What is tall man letters?
This test analyzes a specific enzyme which looks for heart damage, which can indicate a Myocardial Infarction.
What is troponin?
This is an area which has been decontaminated to perform a procedure.
What is a sterile field?
If the patient has an abrasion, contusion or laceration on their face, this finding in the physical exam needs to be taken out, and replaced with the abnormal findings.
What is "atraumatic?"
The temperature of a patient which is considered a fever.
What is 100.4 *F
This in placed in the Prescription orders section of the chart, and indicates that the patient cannot tolerate the generic version of a medication.
(give the abbreviation and what the word stands for)
What is DAW, (dispense as written)?
This is type of order, which is placed in the Manage Orders tab, when the physician you are working with is trying to get in touch with another physician regarding the care of a patient.
What is the ED contact order?
This is the electrical signature of the heartbeat on any EKG.
What is the QRS complex?
This is a list of all diagnoses a patient currently has.
What is a problem list?
This addresses the use and disclosure of individuals’ health information called “Protected Health Information (PHI)”
(give the abbreviation, and what it stands for)
What is HIPAA, (Health Insurance Portability and Accountability Act)?
This office is responsible for protecting the integrity of Health and Human Services (HHS) programs, e.g. Medicare.
(ask if you would like a hint)
What is the Office of Inspector General?
This is the free type box in the prescription orders, which allows the scribe/physician to type specific instructions about the medication prescribed.
What is the patient sig box?
This is the general direction of electrical forces on an EKG.
What is the axis of an EKG?
This is the individual you go to if you run into a situation where you feel you have been asked to do something out of your scope.
Who/What is the scribe company representative?
This is the fourth character in the ICD-10 code.
What is etiology of disease?
This is the term used to account for the degree to which an organization is using electronic medical records.
(ask if you would like a hint)
What is "meaningful use?"
This type of imaging requires there to be clarification as to whether contrast is going to be used or not.
What is a CT scan?
These leads of a 12 lead EKG are placed on the patient's precordium.
What are leads V1-V6?
This is a finding in the normal physical exam template which explains that the patient does not have any unilateral weakness, tongue deviation, facial droop, acute hearing problems or slurred speech.
What is "No focal deficits?"