Term
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Definition
Manages the Emergency Department
patient flow |
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Term
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Definition
| Nurse Practitioner (LNP) or Physician Assitant (PA) that works under the supervision of a physician to diagnose and treat patients |
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Term
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Definition
| Records medical histories, symptoms, monitors the patient, starts IVs, administers medications, and assists with procedures. |
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Term
Respiratory Therapist (RT)
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Definition
| Administers "breathing treatments" and assists with managing a patient's airway |
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Term
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Definition
| Helps the nurse and assists with procedures |
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Term
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Definition
| Places physician's orders, answers phone calls, pages other specialists/doctors, and organizes the patients paperwork. |
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Term
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Definition
| What the patient is complaining of; Feeling |
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Term
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Definition
| What the provider notes about the patient; Lab results, EKG, or Work-ups |
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Term
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Definition
| Pain is what the patient is feeling (subjective), and Tenderness is the Physician's Assesment (objective). |
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Term
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Definition
| Normal, nothing of concern |
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Definition
| The doctor's judgment of discomfort |
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Term
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Definition
| An individual's normal state of being |
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Term
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Definition
| The state of having a fever, concerning for infection |
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Term
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Definition
| New onset, likely concerning |
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Term
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Definition
| Long-standing, not of direct concern |
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Term
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Definition
| Listening with a stethoscope |
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Term
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Definition
| The act of pressing on an area (by the doctor) |
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Term
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Definition
| Admitted to the hospital overnight |
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Term
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Definition
| Seen and sent home the same day |
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Term
| Who is our Emergency Room's specific hand-written documentation system provider? |
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Definition
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Term
Subjective Complaints
on patient chart |
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Definition
| History of Present Illness (HPI) and Review of Systems (ROS) |
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Term
Objective Evaluation
on a patient's chart |
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Definition
| Physical Examination (PE) and ED Course (Labs, XR, Re-evals, Consults) |
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Term
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Definition
| Any medication that causes a rash, itching, swelling, or difficulty breathing |
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Term
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Definition
| Not a true allergy; example: medication causes vomitting |
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Term
| The patient was given an antiemetic while in the ED |
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Definition
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Term
| The EKG shows Normal Sinus Rhythm (NSR) |
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Definition
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Term
| The patient came to the ED for chest pain |
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Definition
| Goes in the History of Present Illness |
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Term
| The patient stubbed their toe last week |
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Definition
| Goes in the Review of Systems |
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Term
| The Complete Blood Count (CBC) shows anemia |
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Definition
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Term
| The patient is in no acute distress |
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Definition
| Goes in the Physical Exam |
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Term
| The patient has high cholesterol |
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Definition
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Term
| The patient feels better after the antiemetic |
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Definition
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Term
| There is tenderness of the RUQ |
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Definition
| Goes in the Physical Exam |
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Term
| The patients mother has heart disease |
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Usually Hypothyroidism, sometimes Hyperthyroidism |
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Term
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Definition
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Term
| "I only take pills for my diabetes" or they regulate with exercise or diet |
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Definition
| Non-Insulin Dependent Diabetes Mellitus (NIDDM) |
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Term
| "I take shots (insulin) for my diabetes" |
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Definition
| Insulin Dependent Diabetes Mellitus (IDDM) |
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Term
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Definition
| Usually Coronary Artery Disease (CAD) |
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Term
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Definition
| Myocardial Infarction (MI) and CAD (if a patient has ever had an MI they have CAD) |
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Term
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Definition
| Congestive Heart Failure (CHF) |
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Term
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Definition
| Atrial Fibrillation (A-Fib) |
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Term
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Definition
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Term
Episodes of abnormally fast/racing heartbeat |
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Definition
| Supraventricular Tachycardia (SVT) |
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Term
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Definition
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Term
Emphysema/Chronic Bronchitis |
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Definition
| Chronic Obstructive Pulmonary Disease (COPD) |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Gastroesophageal Reflux Disease (GERD) |
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Term
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Definition
| Gastric Ulcer or Peptic Ulcer Disease (PUD) |
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Term
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Definition
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Term
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Definition
| Hepatitis A, B, or C (inflammation of the Liver); Can be written as Hep A, B, or C (C is Chronic) |
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Term
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Definition
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Term
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Definition
| Crohn's Disease (Large Intestine/colon; pain in the RLQ) or Ulcerative Colitis (Pain in Left Side, Descending Colon) |
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Term
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Definition
| Irritable Bowel Syndrome (IBS); irregular bowel, mostly small intestine |
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Term
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Definition
| Urinary Tract Infection (UTI) |
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Term
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Definition
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Term
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Definition
| Renal Calculi or Renal Stones |
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Term
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Definition
| Chronic Renal Failure (CRF) on dialysis (aka CKD: Chronic Kidney Disease); ESRF=Dialysis |
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Term
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Definition
| Cerebrovascular Accident (CVA) |
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Term
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Definition
| Transient Ischemic Attack (TIA); usually gone within an hour or so |
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Term
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Definition
| Seizure Disorder/Epilepsy also written as Sz Disorder |
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Term
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Definition
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Term
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Definition
| Bipolar Disorder/Acceptable to just write Bipolar |
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Term
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Definition
| Schizophrenia; Schizo Effect Disorder is not the same: it is when they have components but are not fully diagnosed |
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Term
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Definition
EtOH abuse or Alcoholism
(typically more then 4 or 5 drinks a day or show withdrawal symptoms "the shakes") |
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Term
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Definition
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Term
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Definition
| Abdominal Aortic Aneurysm (AAA) |
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Term
"Bad blood flow to my legs" |
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Definition
| Peripheral Vascular Disease (PVD) |
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Term
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Definition
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Term
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Definition
| Degenerative Disc Disease (DDD) |
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Term
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Definition
| Usually Osteoarthritis (OA) sometimes Rheumatoid Arthritis (RA) |
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Term
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Definition
| Degenerative Joint Disease (DJD) |
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Term
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Definition
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Term
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Definition
| Cancer or Carcinoma (CA): Brain, Breast, Lung, Colon, Prostate, Ovarian, Skin, Bone, Leukemia, or Lymphoma, Pancreas |
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Term
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Definition
| With metastases to the... |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Status-post surgical resection |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Pressure Equalizer (P.E.) Tubes |
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Term
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Definition
| Coronary Artery Bypass Graft (CABG) "Cabbage"; Indicative of Past CAD; CABG x2 = Dbl Bypass |
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Term
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Definition
| Coronary Stents; indicative of past CAD |
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Term
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Definition
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Term
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Definition
| Angioplasty; indicative of past CAD |
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Term
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Definition
| Valve repair or replacement (with bovine "cow" or mechanical or pig) |
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Term
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Definition
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Term
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Definition
| Automatic Implanted Cardiac Defibrillator (AICD) |
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Term
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Definition
Afib s/p after cardiac ablation; must specify what kind of ablation |
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Term
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Definition
| Mastectomy vs. Lump removal: Lumpectomy |
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Term
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Definition
| Tracheostomy (commonly called a trach) |
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Term
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Definition
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Term
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Definition
| Appendectomy; written as appy on charts but must write out full word |
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Term
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Definition
| Cholecystectomy; written as chole on chart but must alway write out full word |
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Term
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Definition
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Term
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Definition
| Partial Colectomy aka Bowel resection |
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Term
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Definition
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Term
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Definition
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Term
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Definition
| Gastric Bypass; Differentiate from CABG |
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Term
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Definition
| Hysterectomy (partial vs. total) |
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Term
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Definition
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Term
Removal of Ovary, Uterus, and Fallopian Tubes |
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Definition
Total Hysterectomy; written as TAH/BSO
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Term
Ovary and Fallopian Tubes Removed |
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Definition
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Term
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Definition
| Tubal Ligation (female) or Vasectomy (male) |
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Term
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Definition
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Term
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Definition
| Prostatectomy (most often Trans-Urethral Removal of the Prostate, or TURP) |
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Term
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Definition
| Carotid Endarterectomy; due to plaque |
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Term
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Definition
| Craniotomy (brain bleed vs. brain CA) |
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Term
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Definition
| Ventriculoperitoneal (VP) Shunt |
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Term
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Definition
AV (arteriovenous) Fistula
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Term
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Definition
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Term
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Definition
| Peripherally Inserted Central Catheter (PICC) |
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Term
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Definition
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Term
Clot Filter (lower abdomen) |
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Definition
| IVC (inferior vena cava) Filter |
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Term
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Definition
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Term
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Definition
| Above Knee Amputation (AKA) Below Knee Amputation (BKA) |
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Term
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Definition
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Term
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Definition
| Hardware aka ORIF (open reduction/internal fixation) |
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Term
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Definition
| Cervical Spine Fusion; C-spine fusion; Cervical Fusion |
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Term
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Definition
| Lumbar Spinal Fusion or L-spine Fusion |
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Term
Important Family History to Record |
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Definition
General: HTN, DM, CA
Cardiac: CAD/MI at less than 55 yrs old
Pulmonary: PE, Astma
Abdominal: Cholecystitis
GU: Kidney Stones
Neuro: CVA, Aneurysm, Seizures
Other: Sickle-cell, DVT
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Term
Important Social History (SHx) |
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Definition
EtOH: Daily or Occasionally/Social or Never
Tobacco: current (#ppd, # of years; calc into pack per years, asked pack days, one pack has 20), Former (quit year), or Never
Illicit Drugs: What Drug?, How Taken?, When?
Occupation
Living Circumstances: Alone, with Fam, Homeless,Nursing home,Hospice (important in elderly)
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