Wait, why are they here? (HPI)
Identify the error in this sentence from an example HPI: "Patient reports intermittent chest pain that began while running on Thursday".
What is Thursday (or days of the week)?
Who the physical exam is obtained from
Who is the provider/physician?
2 labs implied by basic labs
What are CBC and CMP?
Information you need to document for an imaging study
What is type of image (x-ray, CT), body location, and presence of contrast (or views)?
Patient leaves the emergency department without telling staff or the provider. This is known as....
What is elopement?
3 HPI elements
What is SCRATCH-MD? (Severity, Context, Region/Radiation, Associated symptoms, Timing, Character - Modifying Factors, Duration/Onset)
The body system (or systems) that you would document "bilateral CVA tenderness"
What are back and musculoskeletal?
The condition name for a patient suffering from if they have an elevated TSH
What is hypothyroidism?
Patient presents with complaints of headache and on initial encounter, provides a copy of his outside MR Brain report from 2 days ago. During this time, you should be...
What is documenting this information in the "Documents Reviewed" section using "Old records reviewed" macro?
Your provider runs the patient’s case by another provider/specialist. During this time you should be...
What is documenting the conversation in the calls and consults section?
2 examples of clinical situations that indicate documenting a caveat
What is clinical condition, dementia, cognitive impairment, physical impairment, and language barrier?
Unlike the HPI, the physical exam includes which type of information
What is objective?
The Hemoglobin level that warrants blood transfusion in the Emergency Department
What is <7?
The type of score you should prompt your provider for when a patients presents with chest pain
What is HEART score?
All patients who received conscious sedation in the ED must have these 2 follow up instructions...
What is "Moderate Conscious Sedation, easy-to-read" and "Moderate Conscious Sedation, Care After"?
An important thing to document if the patient does not speak English
What is "used translator" or "Used Cyracom interpreter"?
DAILY DOUBLE: The total amount of body systems needed to be addressed for a level 5
What is 8?
Elevated troponin can indicated possible...
What is Myocardial Infarction?
3 examples of risk factors for Coronary Artery Disease
What is family history of CAD, tobacco use, HTN, HLD, Diabetes, age, and/or obesity?
The 3 items needed for documenting calls/consults
What is: time, who you spoke with, what you discussed, and the outcome of the conversation?
2 pieces of information needed in the HPI if patient presents for post surgical wound check...
What is the name of the surgeon, date of surgery, location of wound, and/or hospital surgery took place?
Your provider states "4/5 weakness in the left upper extremity". Name one contradiction in most providers physical exams that may need to be removed because of this.
What is "No focal neurological deficits" or "Equal/Normal Strength"?
The patient has an elevated D-Dimer. This typically indicates...
What are blood clotting disorders such as DVT or PE?
2 items you must prompt your provider for when a patient has conscious sedation in the ED
What are ASA and Mallampati scores?
A patient has been admitted to the ICU. Two questions you should ask your provider are...
What are the admitting diagnoses? Who is the attending patient is admitted under? What is their condition?