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Details

MDM and Labs Review
Review of labs in the MDM
24
Medical
Undergraduate 1
02/13/2011

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Cards

Term
Name five things found in the MDM
Definition
Medications, treatments, counseling, differential diagnosis, lab tests ordered, radiologic tests, procedures
Term
How many elements are need for Cardiac Monitoring?
Definition
2 or more
Term
What three things can be used for CM?
Definition
rate, rhythm, and whether ectopy is present/absent
Term
Pulse Oximetry requires what three things to be documented?
Definition
percentage value, O2 details, and interpretation
Term
ECG
Definition
electrocardiogram
Term
ABGs
Definition
arterial blood gas levels
Term
How many elements are required for ECG?
Definition
4 or more
Term
What are some things that can be used to document ECG?
Definition
rate/rhythm, QRS complex, QT interval, ST segment, T waves, P waves, PR interval; interpretation; who interpreted it
Term
what is need to document ABGs
Definition
pH, O2, HCO3, CO2; interpretation
Term
X-ray documentation reqs
Definition
# of views, 3 findings, & "interpreted by"
Term
CXR findings
Definition
heart size, mediastinum, infiltrates, effusion
Term
Abd X-ray findings
Definition
bowel gas pattern, free air, free fluid, obstruction, stool amount
Term
Ext X-ray possible findings
Definition
alignment, fracture, fracture details, soft tissue
Term
CT scans and MRIs are interpreted by a....
Definition
raidiologist; note the significant findings of each test
Term
ectopy
Definition
abn heart rhythm
Term
CMP
Definition
Comprehensive metabolic panel
Term
Laceration documentation
Definition
length, description, type/dose of anesthetic, type/extent cleaning, type of suture or closure material, method of closure, number of sutures
Term
Splinting documentation
Definition
technique, immpolization equip used, result, complications?, crutches?, who performed it
Term
Conscious sedation documentation
Definition
pre-sedation status, time it began, end, and duration, monitoring in place, post sedation status, type/dose of med administered
Term
Intubation documentation
Definition
reason, meds admin., equip. used, complications
Term
Call time?
Definition
time the ED puts call out to the consult
Term
Contact time?
Definition
time they actually speak with consult
Term
Counseling
Definition
an discussions the physician has with the pt in the ED
Term
Differential diagnosis
Definition
weighing the probability of one disease vs another
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