Scribe america training

cc (chief complaint)

why patient came in today

EMR

Electronic Medical Record

EHR

Electronic Health Record

Subjective

patients feelings

objective

doctors findings of reproducible pain

NEW PATIENT

**can still be considered new even if they have been there just if they havent been in 3 yrs

Diagnostic

new problem : goal is to do workup and fix issue

Health managment

check up : goal is preventative care

CLINIC FLOW

1. Check in & chief complaint

2. History & physical

3. orders & results

4. assesment and plan

5. Check out

KEY vital signs

HR: Heart rate (bpm)

BP: blood pressure (mmgHg)

RR: Respiroty Rate

T: temperature

SaO2: Oxygen saturation (%)

Height, wieght, smoking status, review allergies and medications

HPI

HISOTRY OF PRESENT ILLNESS

ROS

Review of Systems

DDX

only for diagnostic**** = list of possible conditions patient might have based on reported symptoms

SOAP

Subjective, objective, Assesment, plan

Subjective

History of present illness (HPI), Review of Systems

Past history

Medical, surgical, social, famililal

Objective

Physical Exam (PE) , orders and results

Assesment

current diagnosis

Plan

Treatment plan and follow up

High blood pressure

Hypertension (HTN)

High cholesterol

Hyperlipidemia (HLD)

Diabetes

Diabetes Mellitus (DM)

“I only take pills for my diabetes”

Non - insulin dependent Diabetes Mellitus (NIDDM)

“I take shots for my diabetes”

Insulin dependent Diabtes Mellitus (IDDM)

Heart Disease

Cornary Artery Disease (CAD)

Heart Attack

myocardial infarction (MI) and (CAD)

Heart Failure

congestive heart failure (CHF)

Irregular heart beat

arrythmia

Emphysema or chronic bronchitis

chronic obstructive pulmonary disease (COPD)

Blood clot in the lung

pulmonary embolism (PE)

pneumonia or lung infection

pneumonia (PNA)

Reflux

Gastroesophageal Reflux Disease (GERD)

Ulcers

Gastric Ulcer or peptic Ulcer Disease (PUD)

Kidney Infection

Pyelonephritis

“Im on dialysis”

Chronic Kidney Disease (CKD) **** on dialysis

Enlarged Prostate

Benign Prostatic Hyperplasia (BPH)

Stroke

Cerebrovascular Accident (CVA)

“blood clot in the brain”

Ischemic CVA

Brain Bleed

Hemorrhagic CVA

“ Mini Stroke”

Transient Ischemic Attack (TIA)

Blood Clot in my leg

Deep Vein Thrombosis (DVT)

“Bulge in my aorta”

Aortic Aneurysm

“Bad blood flow in my legs”

Peripheral Vascular Disease (PVD)

Cancer

Cancer or Carcinoma (CA)

Spread to my…

With mettastiss to the ….

Chemo

chemotherapy

Radiation

Radiation therapy

They cut it out

Status - post surgical resection

“cancer is gone”

In remission

Tonsils removed

Tonsillectomy

Adenoids removed

Adenoidectomy

“Neck arteries cleaned”

carotid endarterectomy

Leg amputated

Above knee amputation (AKA)

Below knee amputation (BKA)

Joint repair

arthroplasty

“Balloon in my heart”

Angioplasty = PMhx CAD

“Stents in my heart”

Coronary Stents = PMHx CAD

Heart bypass

Cornoary artery bypass graft (CABG) = PMHx CAD

Breast removal

Mastectomy

part of lung removed

partial lobectomy

Appendix removed

Appendectomy

Gallbladder removed

cholecystectomy

part of colon removed

partial colectomy

spleen removed

splenectomy

Kidney removed

Nephrectomy

Uterus removed

Hysterectomy

Ovary removed

oophorectomy

Younger age of early onset

under age 55

PMHx, PSHx

Past medical history

Past surgical history

Symptoms of allergic reaction

rash, itching, swelling, difficulty breathing

tubal ligation

tubes tied

medical term for fainting

syncope

paresthesias

tingling