Chart Components
Medical Conditions/Diseases
Anatomy
Medical Procedures/Surgeries
Labs/Imaging
100
The reason the patient is being seen by a medical provider.
What is the chief complaint.
100
A condition in which there's a delay or obstruction along the pathway that electrical impulses travel to make your heart beat.
What is a Bundle Branch Block?
100
In front of or further toward the front
What is Anterior?
100
Surgical removal of the gallbladder
What is Cholecystectomy
100
A lab ordered to check for anemia or infection
What is a CBC?
200
This section of the chart is used to expand and further describe the chief complaint. It is typically a long paragraph narrative which describes different characteristics of the chief complaint.
What is History of present illness.
200
Damage, blockages or disease in the blood vessels that supply the heart with blood.
What is Coronary Artery Disease (CAD)
200
Nearer to where the limb joins the body.
What is Proximal?
200
A small device placed in your chest or abdomen if you have an irregular heartbeat or are at risk for sudden cardiac arrest. It sends electrical pulses or shocks to the heart when it senses any abnormalities in heartbeat.
What is Implantable Cardiac Defibrillator (ICD)
200
A blood test which checks for specific indicators of damage to the heart muscle (myocardium). This is commonly checked in people with chest pain.
What are troponins?
300
This section of the chart is a list of body systems with common symptoms from each body system
What is the Review of Systems (ROS)
300
An irregular, often rapid heart rate that commonly causes poor blood flow. The heart's upper chambers (atria) beat out of coordination with the lower chambers (ventricles).
What is Atrial Fibrillation (A-Fib)
300
The body lying flat faced upward
What is Supine?
300
Surgical procedure used to treat Coronary Artery Disease (CAD). A blood vessel is removed from one area of the body (chest, arm or leg) and placed in the heart around the area or areas of narrowing to "bypass" the blockages and restore blood flow to the heart muscle.
What is Coronary Artery Bypass Graft (CABG)
300
A test that translates sound waves into pictures of the veins to check for blood clots (DVTs) or venous insufficiency
What is a Venous Doppler?
400
This section of the chart is where the scribe documents what the medical provider found when examining the patient.
What is the Physical exam
400
Narrowing of the blood vessels in the neck that carry blood from the heart to the brain.
What is Carotid artery stenosis?
400
Turning the palm of the hand upward by medial forearm rotation.
What is Supination?
400
A procedure done with a rotary cutter head to remove atherosclerotic plaque from an artery.
What is an atherectomy?
400
A small device implanted under the skin of the chest to monitor the heart's electrical activity
What is an ILR?
500
Anything that makes the chief complaint better or worse.
What is Modifying factors
500
Widening of an artery due to pressure on the weakened tissue wall causing formation of a sac of blood.
What is an Aneurysm?
500
Behind the eyes. Common place for migraines.
What is Retro-Orbital region.
500
A procedure that is used to correct plaque in the arteries by threading a tube through a blood vessel in the arm or groin to the involved site. The tube has a balloon at the end which is then inflated to push the plaque outward against the wall to restore blood flow
What is an angioplasty?
500
A lab likely to be ordered for someone who has a history of Thrombocytopenia.
What is a CBC?
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