Chart Components
Medical Conditions/Diseases
Surgeries
Medical Procedures
Advanced Labs
100
Any long term diagnosed medical conditions for a patient's immediate family (Mother, Father, Grandparents and Siblings).
What is the patient's family history?
100
A life-threatening condition which occurs when something restricts or blocks blood flow to the heart. Without blood, heart tissue loses oxygen and dies.
What is a Myocardial Infarction (MI)?
100
Surgical removal of the ovaries
What is Oophorectomy
100
A procedure often done on a patient at the beginning of their appointment (with a cardiologist) which gives an Interpretation of the electrical activity of the heart over a period of time, as detected by electrodes attached to the outer surface of the skin and recorded by a device external to the body.
What is an Electrocardiogram (EKG or ECG)
100
A lab that shows an average of blood sugar control over the past 2 to 3 months.
What is Hemoglobin A1c (HbA1c)
200
The section that the scribe is responsible for updating if the patient has been newly diagnosed with diabetes since his/her last visit with his/her PCP.
What is the past medical history section?
200
An important measurement used in determining how well your heart is pumping out blood and in diagnosing and tracking heart failure.
What is an Ejection Fraction (EF) or Left Ventricular Ejection Fraction (LVEF)?
200
A tube-shaped device is placed in the coronary arteries that supply blood to the heart, to keep the arteries open in the treatment of Coronary Artery Disease (CAD)
What is a Coronary Stent
200
Used to assess for fainting episodes due to sudden changes in blood pressure or heart rate. Designed to detect one of the most common causes of fainting or lightheadedness, a phenomenon known as postural hypotension (orthostatic hypotension)
What is a TTT (Tilt Table Test)?
200
A lab often ordered for someone on anticoagulation therapy like Warfarin/Coumadin
What is PT/INR
300
The section of the chart where the scribes document which symptoms were asked and whether the patient has experienced that symptom or not.
What is the Review of symptoms (ROS)?
300
A disease in which someone might experience cramping or pain of the lower extremities with ambulation
What is Peripheral artery disease (PAD)?
300
A procedure performed to scar/destroy tissue in your heart that's allowing incorrect electrical signals to cause an abnormal heart rhythm
What is an ablation?
300
A test used to evaluate cardiac function while the heart is under stressed conditions, either during exercise or with the help of a radioisotope
What is a Stress Test
300
A lab that is commonly ordered for a patient with chronic renal insufficiency and has his/her GFR closely monitored.
What is a CMP (Comprehensive Metabolic Panel) or BMP (Basic Metabolic Panel)
400
This section of the chart is where the scribe records the diagnoses for the patient's visit. This includes any chronic, long term illnesses that were discussed as well as any new acute complaints.
What is the Assessment/Diagnosis section?
400
An acquired or hereditary disease of heart muscle, this condition makes it hard for the heart to deliver blood to the body, and can lead to heart failure.
What is Cardiomyopathy?
400
An x-ray test in which the radiologist injects a dye into a blood vessel and takes an x-ray while the dye is being injected. Typically used to distinguish the vascular anatomy of a part of the body, such as the heart.
What is an angiogram?
400
A battery-operated portable device that measures and records your heart's activity (ECG) continuously for 24 to 48 hours or longer depending on the type of monitoring used.
What is a Holter monitor
400
A lab typically checked in patients that might have a PE
What is a D-dimer?
500
The section where the PROVIDER documents any new medications he/she is prescribing the patient
What is the treatment plan section?
500
A condition in which the aortic valve doesn't close tightly allowing some of the blood to leak back into the left ventricle
What is aortic regurgitation?
500
A surgical procedure used to reduce the risk of stroke by correcting stenosis (narrowing) in the carotid artery
What is Carotid Endarterectomy
500
An invasive study which allows doctors to assess the heart's electrical system and induce arrhythmias under controlled conditions. Doctors can then locate the sites which are causing arrhythmias.
What is an EP study?
500
A lab sometimes ordered by a medical provider (like a cardiologist) to monitor someone's heart failure
What is NT-B-type Natriuretic Peptide (BNP) blood test
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