SCRIBE MANUAL

Methodist University Hospital

Emergency Department

 

October, 2009

 

 

 

 

Compiled by Rachel Carter

 

 

 

 

 

 

 

 

 

 

CONTENTS

I. Basic Overview

II. The Chart Piece by Piece

III. Miscellaneous Information

IV. Terminology

V. Procedures

VI. Abbreviations

VII. Lab/Electrolyte Values

IX. Anatomical Positions

X. Signs

 

 

 

 

 

 

 

 

 

 

I. Basic Overview

Congratulations on becoming a medical scribe at Methodist University Hospital. This job will allow you to take a glance into the medical field from the doctor's viewpoint. This is an extraordinary learning opportunity, especially for those of you who want to enter into medical school. As a scribe, you will:

       assist the Emergency Department Physician (EDP) with documentation of the medical record of each patients stay in the ED        accompany the EDP into the patient exam room and transcribe a history & physical exam as performed by the EDP        record the results of any labs, x-rays, CTs, EKGs, or consultation with the patient’s family members and other physicians

AT NO TIME DURING YOUR JOB WILL YOU BE EXPECTED TO INTERACT, EITHER PHYSICALLY OR VERBALLY, WITH THE PATIENT. Your job is strictly to record what goes on during the examination and to accurately document the patient's medical history. Never touch a patient or ask any direct questions of the patient. Uniform for this job includes scrubs (top and bottom) for men and women. Men can also wear dress pants and a white lab coat if desired. Always wear your badge. You cannot work if you do not have your badge on your person. Bring at least 2 pens to work. Be prepared to see patients the moment you set foot into the ED. Be sure to bring food/drink with you to work. There is a cafeteria here, but the food is a tad expensive. You'd be surprised how hungry you get during a shift, so be sure to pack a snack. There is a little fridge in our work space and a microwave in the nurses' lounge.

Because you are working around patients, there is a strict code of conduct and code of ethics which must be adhered to. Always act professionally in front of patients. If you are uncomfortable in a situation, leave quietly and return to your computer and ask the doctor to relay the information to you when he returns from the patient's room. All information pertaining to a patient is strictly confidential - never, ever, ever discuss a patient with any other party other than the health care staff directly taking care of the patient. HIPPA (Health Insurance Portability and Accountability Act) enacted by Congress in 1996 strictly enforces keeping all patient information secure and confidential.

 

 

 

 

 

Methodist University Hospital uses the CERNER system to chart on a patient. To log on to CERNER:

1. Open Internet Explorer - you will automatically be taken to the Methodist Home Page

2. Click on "My Apps" at the top right hand corner of the page

3. Log in using your user name and password as assigned to you

4. Once logged in, click on "First Net" - this will open up the main board of the CERNER system

Note: You will be asked to click Yes/No for 2 questions after you click on First Net - one asks if you want to be checked in as an available provider, the second asks if you want to set a default relationship with the patients. Click NO for both of these questions.

 

The Layout of CERNER

When you first log into CERNER First Net, you will taken to a board that shows all of the patients currently in the ER, both in rooms and the waiting room.

-The rooms listed under the "Bed" tab indicate what room the patient is in.

-The name under the "Name" tab indicates the name of the patient.

-The number under the "S/A" tab indicates the age of the patient.

-The complaint listed under the "Reason for visit" tab is the patient's chief complaint.

-The symbols under the "Events" and "Pt Care" tabs is a method of communication between the doctors and nurses and is not of concern for the scribes.

-Under the "L" tab, it will show how many labs have been completed (if labs are ordered). If you see something like 4/7, this means 4 out of 7 labs that have been ordered have been completed. If you see a green box, this means that all labs have been completed and you can now insert the results into the chart.

-Under the "X" tab, it will tell you if any X-rays or CTs have been completed. The same thing applies for this box - if it reads 1/2, then one out of two x-rays/CTs that have been ordered have been completed; if there is a green box, it means the x-rays/CTs have been completed and the reports are ready to insert into the chart.

-The initials under the "MD" stand for the doctor that is seeing the patient. If a doctor wants you to place his name next to a patient, right click on the blank box under the MD tab beside the the patient's name, then click "Edit MD" - then scroll down under "Treating MD" and chose the doctor that wishes his name assigned to the patient.

-If there are initials under the "Res" or "NP" tab by a patient's name, this means a resident or a nurse practitioner is seeing the patient. You do not do notes on patients that the residents or nurse practitioners see. You may do a brief addendum, but the doctor will always instruct you on exactly what information he wants inserted.

-Under the "Comments" tab, you can insert critical information concerning the patient's situation. For example, if a patient's potassium is 8.2 (very high), you could type in "K 8.2." If the patient is being discharged, type "DC" in the box. If the patient is being put on Track 3 for a cardiac stress test, type "Track 3" in the box.

 

Starting a New Note

To open a new note on a patient:

1. click on the box to the left of the patient's room number (often there is a yellow or red star in this box)

2.click on the PNED (Power Note Emergency Department) tab at the top of the page

3. click on the "+Add" button at the top left hand corner of the page

There are 2 options that you can now take:

a) use a precompleted template

b) use a blank template

If you are a new scribe, begin with the blank templates. By using blank templates, you will learn more about the note because you must manually insert all of the information. After awhile, if you want to use precompleted templates, you can do this. However - some doctors do not wish you to use the precompleted. Other doctors prefer you to use precompleted. The safest method to go about this is to simply ask the doctor which they prefer.

4a. to open a precompleted template, go under the "Precompleted" tab and search for the proper template that matches the patient's chart. For example if the patient is here for shortness of breath, scroll down the list until you find the precompleted template for shortness of breath. There might be more than one precompleted template for a given complaint (Dr. Varner and Dr. Saber each have their own sets of precompleted templates), so its up to the scribe to pick which precompleted template he/she wants to use.

4b. if you wish to use a blank template, look at the box in the lower right hand corner that states "Reason for visit" - often times, the triage nurse puts in the chief complaint here. Just click/highlight the complaint listed and then click OK. If there is no reason listed, you can either: 1. manually search for complaint by typing the complaint into the "Search" box on the right side

of the page; or 2. find the complaint on the left hand side by expanding various boxes and choosing the template you want.

Note: if you cannot find a template which suits the patient's chief complaint, open a "General Medical" template - this template is nonspecific and thus allows you to expand upon a chief complaint in your own words

 

Question: What if the patient comes in with two complaints?

Sometimes, a patient will come in with two complaints. Usually the complaints are related - for example, often times a patient will simultaneously complain of chest pain and shortness of breath. Instead of selecting two templates, choose the complaint of higher priority and open a template on that. Then, once in the note, while you are writing out the patient's story under the History of Present Illness, you can write out that the patient is also complaining of ___. Also include this in the associated symptoms/review of systems section.

However, there are some situations that would require you to select two templates. For example, if someone comes in with a dog bite and fall trauma, it would probably be best to select both "Dog bite" and "Fall" from the list of templates because the two are unrelated.

Layout of the Patient's Chart

At the top of the patient's chart, you will see a horizontal list of various tabs: ED Info, ED Sum, PNED, RAD, LABS, etc etc. Each of these tabs hold certain information about the patient. As a scribe, you will need to know about the following tabs:

a) ED Sum - this is the ED summary of the patient as filled out by the triage nurse. It contains the name of the patient's primary care provider (if the patient has one), the mode of arrival, the social/family/medical history, and information on whether or not the patient's immunization shots are up to date.

b) PNED (Power Note ED) - this is the main tab that you will use while completing a patient's chart. Under this tab, you can open a new chart, access previous ED charts, and work on your current chart.

c) RAD - this is the radiology tab - it contains all of the patient's current and previous radiology reports including x-rays, CTs, ultrasounds, stress tests, etc... To access reports, double click on the report that you wish to view

d) LAB - this is the labs tab - it contains the patient's labs. Sometimes it will reveal only the labs taken on the day of the patient's current visit; sometimes it shows some of the patient's previous labs as well.

e) Reports - this is a very important tab. It contains all of the reports from the patient's previous hospital stays, ER visits, cardiac cath reports, consultations, and history & physical exams. Many times, doctors want part of a patient's previous report (espeically previous Discharge Summaries, which are completed after a patient leaves the hospital after being inpatient) inserted into the chart. To open any report, just double click on the folder that contains the report that you want - then select the report. Make sure to check the date - often times the patient has had multiple ED visits/discharge summaries/etc - so you want to be sure to select the correct one.  

Note: If you ever wish to view more of the patient lab results, radiology reports, discharge summaries, etc etc.. from the past (ex. you want to view a cardiology report from 5 years ago but its only showing you reports from the past year), you must change the search criteria. At the top of where the page when you are viewing labs/x-rays/reports, you will see a blue bar with the current date. Right click on the bar and then select "Change search criteria." Once you click this, a box opens up and you can change the date range for the search criteria and thus view previous labs, test results, etc.

 

 

 

 

 

 

 

 

 

 

 

 

 

Forwarding and Accessing a Current Note

When a scribe opens a new note, that note will be recorded under that scribe's name. A major responsibility of the scribe is to ensure that the note gets forwarded to the doctor's inbox. If the

scribe does not forward the note, the note may be lost/forgotten (especially on very busy days). The doctor's inbox is his way of keeping track of all the patient's he has seen that day - so it is critical that the scribe forwards the note. You only have to forward the note once. You can forward the note at any time before the it is signed. In order to keep track of the notes that you have forwarded, its simpler to forward the note as soon as you initially fill it out.

NEVER, EVER SIGN A NOTE!!!!!! Always click "Save" or "Save and close."

The steps for forwarding a chart are as follows:

1. Open up the patient's chart

2. Click on the PNED tab

3. SINGLE CLICK on the power note you wish to forward (double clicking opens the power note)

4. Hold your mouse over the actual note

5. Right click on the note and then select "Forward"

6. A box will pop up with a line for the doctor's name. Insert the name of the doctor to whom you need to forward the note

 

 

 

 

 

 

 

 

 

II. The Chart Piece by Piece 

1. Basic Information

a) Time seen - click on "Date & Time" and then click OK. For CVAs (strokes) and MIs (heart attacks), you must manually insert the time that you entered the room. Otherwise, simply click OK and don't worry about adjusting the time.

b) History source - this is referring to the sources of information on the patient's story. Click on "Patient" if the patient is awake and alert and able to tell you whats going on. Click on "Family" or "Friend" if family or friends are present to provide information. Click on "EMS" if the ambulance brought the patient in and has information on the patient. Click "Interpreter" if there is a language barrier between the staff and the patient which requires the services of a translator. Click on "Nursing Home Records" if the patient was transported from a nursing home, and the nursing home provides a history of the patient's situation.

c) Arrival mode - this is referring to how the patient arrived at the ER. This is not critical information, so if you are unsure of how the patient arrived, just leave this section blank. You can always click on the "ED Sum" tab at the top left part of the screen - look at the box in the top left hand corner and under "Mode of Arrival" it should list how the patient arrived. "Standard" usually just means the walk-in, and "Amb-ALS" & "Amb BLS" both refer to ambulance. 

d) Vital signs - click "Include Vital Signs from Flowsheet." Do NOT click "Include All" - you only need to insert the initial set of vitals, since you are providing the initial information gathered upon the patient's arrival to the ER. To highlight one set of vitals, simply click on the bar containing the date/time the vitals were taken. Once the set of vitals are highlighted, click "Include Selected."

e) Medications - click on "Include Medication Profile." If you see a notice that reads Validation Status (No Home Medications) then simply exit out of the box and click "None." If a list of medications pops up, click the button at the bottom that reads "Include Med Profile"

f) Allergies - before clicking on anything, look at the top right corner of the patient's chart. You will see it either reads Allergies or No Known Allergies. If you see that it says No Known Allergies, then click "NKMA" (no known medical allergies). If it reads Allergies , click "Include Allergy Profile."  Sometimes, it will say NKDA when you open this box - if you see this, exit out of the box and click on "NKMA." Otherwise, once you see a list of the patient's allergies, click "Include Allergies."

g) Immunizations - to locate this information, click on the ED Sum tab at the top of the patient's chart. Look at the top of the second box (the box that contains the patient's past medical history) - you will see "Last Tetanus" and "Immunization Current" - this is where you can find the patient's immunization record - however! Often times, this is left blank. If you do not see any information here, leave this section blank in the patient's chart. Do NOT click "Per Nurse's Notes" (the information is not in the nurse's notes) - just leave it blank.

h) LMP/Pregnancy History - same as above. If the information is there, it will be with the Tetanus/Immunization information. If there is no LMP (last menstrual period) or pregnancy information, leave this section blank in the chart.

h) History limitation - click "None" if the patient is awake, alert, and able to communicate. Click "Clinical condition" if the patient is unable to communicate (ex. a stroke, major MVA/trauma, cardiac or respiratory arrest). Click "Physical impairment" is the patient is unable to communicate for a physical reason (ex. broken jaw). Click "Language barrier" if the patient is unable to speak English or is deaf.

i) Notes - here is where you insert the Chief Complaint that the triage nurse writes up. To insert the Chief Complaint, click on "Chief Complaint from Nursing Triage Note." This will open a box - do not click "Select All"!! Click "Include Selected" and it will automatically insert one chief complaint. If you click "Select All" it will insert two of the same chief complaints.

 

2. History of Present Illness

a) Presents With - This section reads as sentence, so do not open the box and begin typing a new sentence. Open the "Other" box and begin by finishing the sentence "Patient presents with...." In this section, you will give a brief history of the patient's condition. Information should include things like the circumstances surrounding why the patient came to the ER, any current major medical problems the patient suffers from, if the patient has a history of smoking and/or alcohol/drug abuse, if the patient admits to being noncompliant with medications, etc etc etc. If you are unsure of what to type here, you can ask the doctor for a brief summary

b) Duration - this is referring to the duration of the patient's complaint. For example, if the patient had a 30 minute episode of severe chest pain, you would type in "30 minutes." If the patient had onset of chest pain 4 hours ago and the pain has been constant since then, you would type in "4 hours."

c) Onset - this is referring to the circumstances under which the patient's complaint began. Did it begin abruptly? Did it come on gradually? With exertion? At rest? Often times, this information is unclear in the patient's story, so if you are unsure, either leave the section blank or ask the doctor.

d) Course - click "Resolved" if the patient states his/her complaint/pain has resolved. Click "Decreasing" if the patient's complaint/pain is getting better, but is still present. Click "Constant" if the patient's complaint/pain has been constant since it onset. Click "Increasing" if the patient's complaint/pain has gotten worse since the onset. Click "Episodic" if the patient experiences periodic episodes of pain (if this is the case, be sure to note how long the episodes last). Click "Waxing and Waning" if the patient's complaint/pain seems to come and go.

e) Exacerbating factors - this is referring to what factors make the patient's complaint worse (ex. if the patient's complaint is Shortness of Breath, often time "exertion" will be an exacerbating factor)

f) Mitigating factors - this is referring to what factors make the patient's complain better (ex. if the patient has abdominal pain and throwing up makes him feel better, then "vomiting" will be a mitigating factor)

g) Risk factors - risk factors vary according to what the patient's complaint is. If the patient is noncompliant with their medication (not taking the proper medication for a condition), that is always considered a risk factor. Smoking and alcohol/drug abuse are also always risk factors. HIV/AIDS is also always a risk factor because the patient is severely immunocompromised, meaning they have a decreased ability to fight off infections. If the patient's complaint is chest pain, then hypertension (HTN), diabetes mellitus (DM), and a family history of coronary artery disease (CAD) are examples of risk factors. For abdominal pain, risk factors could include things such as contaminated food/water, alcohol (ETOH) abuse, or gastroenteritis exposure.

h) Prior episodes - this is very important! Always note whether the patient has experienced similar symptoms before or if this is a brand new problem.

Note: Different notes for different complaints contain different questions within the History of Present Illness section. The things listed above are included in every note. However, an MVA (motor vehicle accident) note will contain questions about what time the accident occurred, where was the patient located in the car, and whether or not seat belts were in use and airbags were deployed. A chest pain note will contain questions on what type of pain it is (dull, sharp, cramping, etc) and if the pain radiates to any other part of the body. If you are ever confused or unsure of what to put in a particular section, remember you can always ask the doctor.

 

3. Associated Symptoms

These are symptoms that are typically associated with the patient's chief complaint. For example, if the patient comes in with abdominal pain, typical associated symptoms would include nausea, vomiting, and/or diarrhea. Click on whatever symptoms the patient mentions.

NOTE: Do NOT simply circle negative for the symptoms that do not apply. Double click on symptoms to put a slash through them. 

 

 

 

 

4. Review of Systems

These are similar to the associated symptoms - they are symptoms that are commonly associated with the chief complaint. There is one critical aspect to this section of the chart: on the line that reads "Other significant ROS" you must circle "All systems otherwise negative" As with the associated symptoms, do not simply circle negative for the symptoms that do not apply - double click the symptoms to put a slash through them.

If you are unable to obtain a review of systems, next to "Unable to obtain due to" click on the appropriate box. If the patient is noncommunicative (major head trauma, cardiac/resp arrest), click "Clinical Condition." If the patient is old and has dementia/Alzheimer's, click "Dementia." If the patient has a major change in mental status (stroke/CVA), click "Altered Mental Status." If the patient is uncooperative and refuses to comply during the examination, click "Uncooperative patient."

 

Note: Both the Associated Symptoms and Review of Systems should be what the patient tells the doctor. For example, if the patient states she can't feel her legs, then this would go under the "Neuro" part of either section as "weakness/numbness." Another example is even if the patient does not have an actual fever but states that she/he has felt feverish, you still click on "Fever" under the Constitutional section under Associated Symptoms.

 

5. Past Medical/Social/Family

a) Medical history - to locate this information, click on the "ED Sum" tab at the top of the chart. In the second box from the left, you will see all of the patient's previous medical history listed. Insert the history in its proper location on the chart. For example, if the patient suffers from hypertension (HTN) and chest pain (angina) and has had a heart attack (MI), you would circle "HTN" "angina" and "MI" under the cardiac portion of the medical history. Conditions such as asthma, COPD/emphysema, bronchitis, pneumonia, and sleep apnea would go under respiratory. If the patient has cancer, click on the appropriate cancer - if the specific cancer is not listed, click "Other" and manually insert the type of cancer the patient has. If the patient has diabetes, always click on Diabetes Mellitus Type II - 99% of the diabetics that come into the ER are Type II. Type I diabetics are typically thin and ill-appearing. All other medical history goes under Additional. You can either click on the addition medical conditions, or click on "Other: and manually type out the conditions.

b) Surgical history - this information is located just beneath the medical history under the "ED Sum" tab. Click on the appropriate past surgeries, or click "Other" and manually insert the types of previous surgeries the patient has undergone

c) Family history - the only time you click on anything under the family history section is for chest pain patients who have a family history of hypertension (HTN), diabetes (DM), or coronary artery disease (CAD). Otherwise, click on "Not significant." DO NOT CLICK "REVIEWED AS DOCUMENTED IN CHART" The nurses do not review this information!

d) Social history - this information is also under the "ED Sum" tab. Its located in the box on the far left. Click on the appropriate box for whether or not the patient smokes, drink, or uses any type of drugs. If the patient is homeless or lives in a nursing home, you can enter this information under the "Family/Social situation" section.

 

6. Physical Exam

This is one of the most critical parts of the chart. It is very important to accurately document everything the doctor observes during an exam. Some observations are obvious - for example, if a patient as a left BLK (below-the-knee amputation), and the doctor does not mention this, obviously the scribe should document this in the note. Otherwise, always ask a doctor before you put insert anything

Note: As a scribe, we no longer bill patients for the doctors. However, it is still our responsibility to make sure there is enough documentation completed to bill appropriately. If not enough of the note is completed (epsecially on the physcial exam), then there is documentation lacking concerning what the doctor actually did for the patient - thus the doctor can not properly bill a patient for the care he provided. When you are in the note, look to the bottom left hand corner. You will see a bar with a number inside. As you begin filling out the note, the note begins to fill up with a blue bar. You know that you have completed enough of the note when the bar has filled up to the appropriate number. Sometimes, no matter if you document everything correctly or not, a the bar will not completely fill up. This is just a glitch in the system - just let the doctor know that everything has been documented accurately and he will bill appropriately.

If you ever need to insert more infomation into the physical exam, either for billing purposes or simply because there is something that needs to be documented and there is not an accuate place to document it, right click over "Physical Exam" and then click Insert Sentence. This opens a box with a very long list of parts of the physical exam you can insert. To insert something, click/highlight and click OK (you can select more than one before you click OK).

 

As with Associated Symptoms/Review of Systems, do NOT just circle "WNL" (within normal limits). You need to actually circle the positive/negative symptoms or nomral findings listed.

a) positive symptoms - features that are present but should be absent  - ex. bilateral lower extremitiy edema

b) negative symptoms - features that are absent but should be present - ex. absent breath sounds

c) normal findings - ex. good skin turgor, normal tone, no swelling, etc...

Usually, the following are including in every template's physical exam section:

-General appearance: this is where you indicate if the patient is in distress and then insert a few descriptive words, if needed. For example, if a patient is very old, very sick, and looks like she's wasting way, you could type in "cachectic, chronically ill-appearing." If a patient does not communicate (because of a stroke, dementia, etc etc), type in "verbally noncommunicative." If a patient is dry and dehydrated, type in "appears dehydrated." If there is nothing to indicate, click No Acute Distress

-Skin – this is where you would document if the patient has any rash, lesions, scars, abnormal pigment (such as vitiligo, jaundice, pallor, erythema, etc), eccymoisis (bruising), xerosis, eczema, etc. If everything is normal, click Warm, Dry, and No Pallor.

-Eye – this is where you would document if the patient is blind or has any other eye deficits, or has icterus. If everything is normal, click PERRL, EOMI, and Normal Conjunctiva.

-ENT (Ear, Nose, Throat) – this is where you would document if the patient is lacking teeth/has poor oral hygiene, has dry mucosa of the mouth/throat, or has any kind of redness, swelling, or tenderness in the ear, nose, or throat/mouth. If not, click Oral Mucosa Moist and No Pharyngeal Erythema or Exudate. If the doctor does not exam the ear, nose, and/or throat, do not document that he has done so – simply leave the section blank.

-Neck - this is where you would document if the patient has JVD (jugular vein distention), a tracheotomy tube, or any other notable neck problem. If everything is normal, click Supple and No JVD.

-CV Heart – this is where you document if the patient has any cardiac issues, such as tachy/bradycardia, or a heart murmur. If the patient has a heart murmur, the doctor will always tell you the specific location which you must manually type in. If everything is normal, click Normal Rate and Rhythm and No Extra Heart Sounds.

-Respiratory – this is where you would document if the patient has any respiratory issues, such as tach/bradypnea, wheezing, rales, rhonchi, etc. If everything is normal, click Lungs CTA and Respirations Nonlabored.

-Chest Wall – this is where you would document any abnormalities over the chest wall, such as a subclavian vas cath, scars/bruising over the chest, etc. If everything is normal, click No Deformity.

-Abdomen – this is where you would document any GI problems such as decreased/increased bowel sounds, distention/ascities, tenderness, organomegaly, masses, or if a peg tube is present. If everything is normal, click Soft, Nontender, and Nondistended. When the patient comes in with a GI complaint, you must do an expanded exam on the abdomen. Click the >> next to abdomen and fill out the rest of the section. If there is tenderness, be specific about in which quadrant is tender; if there are scars/masses present, be specific to the location.

-Genital – this is where you would document any abnormalities in the GU system such as bleeding, discharge, swelling, etc. Do not click anything on this section if the doctor does not do an examination of the patient’s genitals – that would be improper documentation.

-Rectal – this section is only to be completed if the doctor performs a rectal exam on a patient. Click >> and indicate the color of the stool obtained and whether the Guaiac Test (testing for blood in the stool) was positive or negative.

-Back - this is where you would document if the patient had any back abnormalities such as tenderness, deformity (ex. Scoliosis), or abnormal range of motion. If the exam is normal, click Normal ROM, No Tenderness, No Deformity.

-Extremity – this is where you would document abnormalities in the upper and lower extremities, such as edema (swelling), erythema, and missing limbs. If everything is normal, click Normal ROM, No Swelling, No Tenderness.

-CV Perfusion – this is where you would document if the patient decreased perfusion in any area of the body. If not, click WNL.

-Psychiatric – this is where you would document any abnormalities such as the patient being anxious, agitated, uncooperative, or flat. If the patient behaves appropriately, click Appropriate.

 

Drawing – you will see this located in various parts of the exam for different templates. If you click on this section, a box will open where you can draw a circle around or a line indicating the location of the patient’s problem. This is a good tool to use for lacerations.

 

7. Medical Decision Making

The only parts of this section of the chart the scribe needs to pay attention to are the EKG, labs, CXR, XR, CT, US, and Calls/Consults. Leave everything else blank

a) EKG - for documentation and billing purposes, it is critical that you record EKGs done on a patient. All chest pain patients will have at least one EKG conducted. A lot of times, the doctors forget to mention what the results of the EKG are, so it is up to the scribe to ask the doctor. The EKG information should include: time (the only time you need to be specific and manually insert the time is for heart attacks; otherwise just click OK) and rate. Click on NSR (Normal Sinus Rhythm) if the EKG is normal. The doctor will specify what else he wants written in.

b) General results (Labs) - once all of a patient's labs have returned, you need to insert the labs into the chart. To do this, click on "Today's Results" under General Results (Flowsheet) - once in the box, click "Select All" and then "Include Selected." Be sure to double check the date at the

top of the labs - sometimes even when you click "Today's Results" you still get labs taken on previous occasions.

c) CXR - this specifically refers to chest x-rays. To insert a patient's CXR, go to the Reports tab at the top of the chart. Double click on the box that reads "Chest 2W"  or "Chest 1W" under the appropriate date (remember to look at the date because some patients have had multiple CXRs that have been completed recently, but you need to insert the current CXR). Once you are in the box that contains the CXR report, highlight the entire report and click Contol C (there is no option to copy/paste under the Edit). Then go back into PNED. Click on "Describe" in the CXR section and then paste the report into the box.

d)XR - this refers to all other x-rays (ankle, forearm, etc etc). The way you insert the x-ray into the chart is the same as stated above.

e) CT - this refers to CTs of the body (trunk, abdomen/pelvis). The way you insert CTs into the chart is the the same as stated above. Note: when a patient has an abdomen CT ordered, a pelvic CT is automatically also ordered. Do not insert both the abdomen and pelvis CT reports into the chart - its the same report.

f) Head CT - this refers specifically to a CT of the head/brain. The way you insert head CT into the chart is the same as stated above.

g) US - this refers to ultrasounds. The way you insert an ultrasound into the chart is same as stated above.

h) Calls/Consults - this is a very important aspect of the chart, especially if the patient is admitted. Whenever the doctor receives a phone call, immediately jot down notes about what the doctor is talking about. As soon as the doctor is off the phone, ask him what physisican he was speaking to and about which patient he was discussing. When you have all the information about the call, click on "Time" to enter the time of the phone call. Then click on "phone call" if the doctor spoke on the phone. If the doctor spoke to another physician in the ER about a patient, do not click phone call. Then open "Other" and describe what was discussed during the phone coversation. You do not have to go into great detail - usually a brief statement will do.

Example 1: "Dr. ___ informed of patient's condition and agrees to admit patient to inpatient bed"

Example 2: "Dr ____ informed of patient's condition - advises that patient be put on new blood pressure medication and discharged home."

 

**If there is a type of test you need to insert a report for - for example, you need to insert a Head CT but there is no Head CT line - just right click over "Medical Decision Making" and click "Insert Sentence." Then select whatever tests you need included and click OK.**

8. Documentation Reviewed

In the section, always click on "ED Nurse." If you look at previous records, click on "Prior records." If you look at previous ER provider notes, click on "Prior ED notes."

Often times, a patient will have been recently discharged from the hospital or been in the ER. If the patient has been in the hospital within the past year, you need to insert the discharge summary from that hospital stay. If the patient has had a cardiac catheterization or a stress test within the past few years, you need to insert the reports into the chart. Some doctors like you to insert previous History and Physical Exams into the chart so that the patient's current condition can be compared with his/her previous condition.

To insert any of the above information, click on the Reports tab at the chart. Look in the box along the left side of the page - you will see many folders containing information about the patient's past medical visits. Double click on the report - highlight the entire report and click Control C to copy the report. Then go back to the PNED and click "Other" - then paste the report into the box and click OK.

 

9. Reexamination

When a doctor goes and checks up on a patient or a nurse comes to the doctor with an update on the patient's status, you can insert a reexam note. To insert a reexam note click on >> next to Reexamination. This expands the Reexamination box and allows you to enter information. Enter the time by clicking "Time." Next to vitals, always click "Per Nurse's Notes." Then, next to Reexmination, click "Describe" and then type out a description of the doctor's/nurse's reexam.

Example 1: "Patient states she still continues to be short of breath and wheezy after 1-hour aerosol treatment. Patient's vitals are stable, but she is diaphoretic. An additional breathing treatment will be ordered."

Example 2: "Patient states his abdominal pain is 100% resolved after drinking the GI Cocktail provided. Pt has defecated twice since his arrival to the ER and states that he is no longer constipated."

 

10. Procedures

This is the section where you document any special procedures performed on the patient including: external jugular IVs (EJ), central lines, femoral sticks, intubations, lumbar punctures, and incision and drainages. EJs and femoral sticks are the only two that do not have an actual separate note that you have to fill out. For these two, click on "Notes" under the Procedure section and describe what the doctor did.

Example: for an external jugular IV, you would write: "left/right EJ performed at (insert time) due to lack of IV access. Procedure tolerated well by patient. Performed by (insert doctor's name)."

Example: for a femoral stick, you would write "left/right femoral stick performed at (insert time) due to lack of IV access. Procedure tolerated well by patient. Performed by (insert doctor's name)."

Laceration repairs also require special documentation. However, the laceration note has a form already included under the Procedure section that you need to fill out if the doctor has to do a laceration repair. Ask the any questions you have regarding the specifics of the procedure (how many sutures used, whether or not irrigation was used, etc etc) 

To insert a procedure note into the chart, right click on "Procedure" then click "Insert Sentence" and then select the specific procedure note you want to insert. See Part V for a list of the procedures that you will need to know how to insert into the patient's chart.

 

11. Impression and Plan

a) Diagnosis - always ask the doctor what you should list under the diagnosis. Some diagnoses will be obvious. For example, if a patient comes in with chest pain, "Chest Pain" is going to be a diagnosis - however there may be additional diagnoses which the doctors wishes you to add.

b) Disposition - you will almost always click "Stable" here. Click "Guarded" if the patient is in very poor condition and is being transmitted to the ICU. Click "Expired" if the patient died.

c) Prescriptions - leave this section blank

d) Pt. education - this is where you select information that will be given to the patient upon the patient's discharge. You do not give the patient any Patient Education if the patient is admitted the hospital or has expired. To complete the patient education section, click on "Pt. education." Under the Instructions tab, you will insert information on the patient's diagnoses and the prescriptions. Ask the doctors for the specific diagnoses and prescriptions he wants you to include. Next, click on the Follow Up tab at the top of the chart. If the patient has a primary care provider (PCP), then it will be listed in the box at the bottom of the page. If it states reads "Nonstaff PCP" this means the patient does not have a PCP and Methodist needs to refer them to a follow up clinic. For patients who do not have insurance, Memphis Health Center is usually the best clinic to refer them to. To select an a clinic, click on the button next to "Organization/Clinic Search" and then scroll down to MEMPHIS HEATH CENTER. If there are any special instructions the doctor wishes to give the patient, you can type them up in the box on the lower right side of the page.

e) Limitations - leave this section blank, unless indicated by the doctor

f) Follow Up - this will automatically be filled out once you fill in the Follow Up section within the patient education

g) Counseled - click "Patient" if you counseled the patient (remember, do not click this if the patient is unresponsive or dead!), and Family/Friend if you talked with family or friends about the patient's condition. Always click on "Regarding Tx Plan" (treatment plan) and "Regarding Dx" (diagnosis) - but only click "Regarding Rx" if you give the patient a prescription.

h) Notes - insert "Scribe: ____" (your name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

III. Miscellaneous Information

1. Where to find caretracks

If a doctor asks you to print out a caretrack (usually it will be for patient with CHF (congestive heart failure) or pneumonia), follow these steps:

a) open Internet explorer and go to home page

b) under "Quick Links" on the left side of the web page, scroll down until you see the tab that says "Protocols, Ordersets, and Caretracks" - click on that

c) in the purple box of the left side of the web page, click "Caretracks" under "Clinical Standards"

d) select the proper caretrack

- the heart failure/CHF caretrack is "CARD Heart Failure Admit - 20412-QM1108"

             - the pneumonia caretrack is "PULM Pneumonia Admission - 21709-QM0409"

 

2. Where to find a patient's Fin Number.

A fin number is a number that corresponds with a specific patient, making it easier for doctors and other health care staff to look up patients' records. If you search for a patient by fin number, you can pull up all of their previous records, including their previous ER visits. Usually, the doctor wants to know the fin number of a patient that is currently being seen. To find the patient's fin number, open the patient's chart and look at the top of the screen. In the grey box, you will see information on the patient such as date of birth, age, sex, and fin number. The fin number is 8 numbers long.

 

3. Alerting the doctor if the patient is on Coumadin.

If a patient is on Coumadin (also known as Warfarin), this can be a very serious piece of information for the doctor. Coumadin is a blood thinner and can thus cause a number of problems for a patient, especially if the patient is there because of a possible stroke or GI bleed. When you click "Include Med Profile" on the chart, always look to see if the patient is on Coumadin. Tell the doctor immediately if you see Coumadin listed.

 

 

4. Locating a chart in the ER.

Many times, a doctor will ask you to fetch a certain patient's chart. The chart will be in one of the following places:

a) with the nurse - look on the white board on the subacute hall to see which nurses have which rooms

b) with the secretary

c) in the patient's room, either on the table or under the patient's mattress (sometimes the chart gets left under the mattress when the patient gets taken to XR or CT)

d) in the chart rack (this is located between the doctor's space and where the nurses sit)

 

 

5. An expired (dead) patient's chart.

There are very specific elements that need to be filled out for a patient that has died:

a) do not include "patient" under history source

b) most times, there will be no vital signs to insert under the Basic Information, so do NOT put "Per Nurse's Notes" - just leave this section blank

c) under the History of Present Illness

       Patient presents with: click to appropriate origin of the arrest - usually its either cardiac or respiratory, not both (cardiorespiratory)        Occurrence: click "Witnessed" if either EMS, family, or a bystander saw the patient go into arrest. Otherwise, click "Found Down" and ask the EMS team for approximately how long the patient was down for        Arrest Etiology: click Cardiac or Respiratory        Initial Cardiac Rhythm: ask EMS        Present Cardiac Rhythm: look at the cardiac monitor or ask a nurse/doctor/EMS        EMS ACLS (Advanced Cardiac Life Support): 

       -click Intubation if the EMS team intubated the patient prior to arrival at the ER; click Manual Compressions if EMS was performing manual CPR on the patient when the patient arrived to the ER

       -note how many times EMS shocked the patient, if they did - do not worry about filling out "at ___ joules" 

       -note what drugs were given - always insert the drugs given under "Meds Given via IV"

       -Prior arrest: click any that apply        -Risk Factors: click any that apply        -Prior neuro deficits: click any that apply

d) under Associated symptoms - at the bottom on the line that reads "Notes" type in "Unable to obtain due to clinical condition"

e) under Review of Systems - under "Other significant review of systems" click "Clinical Condition"

f) under Physical Exam:

       General appearance: unresponsive        Eyes: type in "pupils fixed and dilated"        Airway: click "Oral ET tube" if the patient has been intubated        Respiratory: type in "equal breath sounds with bagging"        Heart: click "absent heart sounds"        Neurological: unresponsive

If the patient has other noticeable conditions such as a peg tube, decubituis ulcers, etc... note these on the exam as well.

g) under Medical Decision making - insert labs (if they were drawn) and CXR report (if one was taken)

h) under Procedure:

    -fill out the critical care section - ask the doctor what things he wants circled

    -fill out any special procedure notes (central line, intubation, etc)

i) under Impression and Plan

-diagnosis: click the appropriate arrest

-condition: click "Expired" - then type in "TOD: ___" under Other

-TOD stands for Time of Death - you must listen for or ask the time that the doctor calls the patient's death

-admit: leave this section blank

-counseled - do NOT click patient - click on family/friend if any are available

 

6. Documentation during an arrest

When a patient comes to the ER in cardiac/respiratory arrest, everything is happening very quickly, so you must be extremely alert to what is going on and what information is being obtained. Immediately note the time that you enter the room. You must either ask the EMS personally or listen to what the EMS tells the nurse in order to get the following needed information: story behind arrest (what time, witnessed versus found down, etc), medicines delivered via IV on route to the ER, whether or not patient was shocked (defibrillated) prior to arrival to ER, whether patient was intubated prior to arrival (and if so, what size tube), and the patient's initial cardiac rhythm. You need to write down what interventions (shocking, medications, etc)  the ER doctor is providing, but you don't have to be specific about the time (the nurses take care of this in their documentation).

On the chart, under the basic information:

1. remember you must manually insert the actual time you went into the patient's room 

2. do NOT list the patient as a history source; instead click EMS (always) and any other sources that apply (family, nursing home records, etc)

3. vital signs - many times, there will be no vitals, especially if the patient is in critical condition. Do NOT click "Per Nurse's Notes" - just leave this blank

4. under "History Limitation" click "Clinical Condition"

Be sure to document special procedures (such as an endotracheal intubation or central line) that the doctor performs.

At the bottom of the chart under Impression and Plan:

1. under Condition, click "Guarded" if the patient survives or "expired" if the patient dies

2. under Counseled, do NOT click "Patient" if the patient remains unresponsive. If there is no family/friends to counsel, just leave this section blank

 

7. Noting if a patient comes in wearing a cervical collar or is on a backboard:

If a patient has suffered trauma, such as assault, a seizure or an MVA (motor vehicle accident), often times the EMS will place a C-collar around the patient's neck and place the patient on a backboard. It is important to note in the patient's chart if either of these are used. Put this information in the story you type out under "Patient presents with..." under the History of Present

Illness. Sentence should read something like, "Prior to arrival to ER, patient was place in a C-collar and was strapped to a backboard."

8. Medical spell check:

Spelling error can cause problems and are unprofessional. Luckily, the CERNER program has a built in spell check - and its a medical spell check, so it actually has most medications and medical terms included. Any time you open a box to type something up, before you close the box, simply click the "Check Spelling" button in the lower left hand corner.

9. Right Click Repeat

Say, for example, that there are 2 (or more) EKGs/x-rays/CTs that you want to insert into the chart. Right click above whatever you want to insert another of, and then select "Repeat." This will add additional lines of whatever test, report, etc... so you can insert as many as you need.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IV. Key Terminology

    a. General/Miscelaneous

       -cachectic - physical wasting away with loss of weight and muscle mass due to disease

       -malaise - feeling of being worn out, weak, fatigued

       -dialysis - process of cleansing the blood by passing it through a special machine; dialysis is necessary when the kidneys are not able to filter the blood

       -embolism (embolus) - clot - can be made of blood, fat, etc...

       -thrombus - blood clot

    b. Stroke related

       -aphasia - loss of power of expression by speech, writing, or signs, or of comprehension of spoken or written language 

       -ataxia - inability to perform coordinated movements 

       -apraxia - loss of ability to perform purposeful movements

       -dysarthria - garbled, nonsensical speech

       -dysphagia - impairment of ability to swallow

       -dysphasia - impairment in speech consisting of lack of coordination and inability to arrange words in their proper order 

       -hemiplegia - loss of motor power on one side of the body

o      -paralysis occurs on opposite side of lesion, so if the bleed is on the right side of the brain, the left side of body will experience the symptoms (and vice versa) 

     c. Body systems

1. Skin

       -jaundice - yellowing of the skin and sclerae by abnormally high blood levels of the bile bilirubin - occurs with anemia and chronic liver conditions

       -erythema - intense redness of skin due to excess blood in dilated superficial capillaries, as in fever or inflammation 

       -vitiligo - skin condition in which there is loss of pigment (color) from areas of skin, resulting in irregular white patches that feel like normal skin

       -diaphoresis - excess sweating

       -abscess - localized collection of pus that is surrounded by swelling (inflammation)

       -eccymoisis - bruising of the skin

       -decubitus ulcers - also called "pressure sores" or "bed sores" - usually occur over bony areas such as shoulder blades, heels, and sacrum

       -Stage I: ulcer appears as a defined area of persistent redness in lightly pigmented skin, skin becomes "boggy" and soft

       -Stage II: partial thickness skin loss involving epidermis, dermis, or both - the ulcer is superficial and presents clinically as an abrasion, blister or shallow crater

       -Stage III: full thickness skin loss involving damage to subcutaneous tissue that may extend down to, but not through, underlying fascia - the ulcer presents clinically as a deep crater

       -Stage IV: full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Can include eschar (thick dry

       black necrotic tissue)

       -exudate - fluid that is oozing from skin, tissue, wound, etc The 3 types include:

o      serous - clear, watery fluid, ex. blister fluid

o      sangiounous - bloody fluid, ex. fresh cut

o      purulent - thick, yellow pus - indicates infection is present

       -dehisence - when a wound is splitting/opening up

       -pallor - pale

       -pruitis - itching

       -edema - swelling related to fluid accumulation in body tissues - usually occurs in the lower extremities

2. Eyes

       -icterus - yellowing/jaundice of the sclera (part of the eye that is normally white)

       -ptosis - drooping of upper eyelid over the iris and possibly covering pupil 

       -diplopia - double vision

       -nystagmus - involuntary, rapid, rhythmic movement of the eyeball 

       -strabismus - any form of disparity of the eye axes – ex. crossed eyes, lazy eye

       -PERRL - "Pupils Equal and Reactive to Light"

       -EOMI - "Extra Ocular Movements Intact"

3. ENT (ear, nose, and throat)

       -edentulous - referring to lack of teeth or very poor dental hygiene

       -vertigo - a spinning, twirling sensation - "the room is spinning" 

       -epistaxis - nosebleed

       -candida - white, cheesy, curdlike patch on tongue due to superficial fungal infection 

4. Cardiac

       -angina - chest pain r/t cardiac problem

       -arrhythmia - irregular heart beat

o      ventricular fibrillation (v fib) - Electrical signals in the ventricles are fired in a very fast and uncontrolled manner, causing the heart to quiver rather than beat and pump blood - very, very serious

o      atrial fibrillation (a fib) - absence of P waves on EKG - most common arrhythmia -  often asymptomatic - may result in palpitations, fainting, chest pain, or congestive heart failure - increased risk for stroke

o      asytole - complete absence of heart electrical activity - often a terminal arrythmia

o      PEA (pulseless electrical activity) - heart rhythm observed on the EKG that should be producing a pulse, but is not

       -bradycardia - heart rate is below 60 beats per minute

       -tachycardia - heart rate is above 100 beats per minute

       -MI (myocardial infarction) - heart attack

       -CABG (Coronary Artery Bypass Graft) - surgical procedure performed to relieve angina and reduce the risk of death from coronary artery disease

       -thrill - palpable vibration of artery - can be felt over chest wall of a patient with a heart murmur, and over a dialysis access shunt

       -cardiac arrest - abrupt cessation of normal circulation of the blood due to failure of the heart to contract effectively - considered a emergency situation

       -murmur - extra heart sounds that are produced as a result of turbulent blood flow

5. Respiratory

       -dyspnea/shortness of breath - difficulty breathing

       -orthopnea- shortness of breath which occurs when lying flat, causing the person to have to sleep propped up in bed or sitting in a chair

       -tachypnea - more than 20 breaths per minute

       -bradypnea - less than 12 breaths per minute

       -rales - crackles or crepitations heard during auscultation of lungs

       -rhonchi- low-pitched, snoring, adventitious lung sound caused by air-flow obstruction from secretion

       -wheezing - high pitched, musical tones heard in the lungs - usually indicative of asthma

       -pleural effusion-  pleural effusion is an accumulation of fluid between the layers of tissue that line the lungs and chest cavity. Symptoms: chest pain, cough, fever, tachypnea, SOB

       -COPD (Chronic Obstructive Pulmonary Disease) - lung disease that makes breathing difficult. Includes chronic bronchitis and emphysema

       -emphysema - air sacs are destroyed inside the lungs

       -chronic bronchitis - swelling and large amounts of mucous collection in the main airways of the lungs

       -PE (pulmonary embolism) - a clot that travels to the lungs and blocks one of the main arteries within the lungs - very serious condition

       -apnea - absence of breathing

       -pneumothorax - collapsed lung

6. Gastrointestinal (GI)

       -stool - feces

       -melena - black, tarry, malodorous stool - indicates blood is present

       -hematochezia - yellow, slimy stool - indicates fat is present

       -Guaiac (rectal) test - a test to determine whether or not stool is Heme (blood) positive

       -hematemesis - throwing up blood

       -ascities - abnormal accumulation of serous fluid within the peritoneal (abdominal) cavity

       -emesis - throw-up, vomit

7. Genitourinary (GU)

o      -hematuria - blood in urine

o      -dysuria - painful urination - often described as a "burning" sensation

o      -polyuria - frequent urination

o      -oliguria - decreased urination

o      -anuria - no urination

o      -amenorrhea - lack of menstuations, often due to poor nutition, anorexia

o      -dysmennorrhea - painful menstruation

o      -incontinence - inability to control bladder/bowel movements - can occur with stress, loss of consciousness, seizure, and in elderly population

o      -UTI (Urinary Tract Infection) - infection of bladder or urinary tract; main 3 symptoms: hematuria, dysuria, and polyuria

        8. Neurologic

       -aneurysm - abnormal widening or ballooning of a portion of an artery due to weakness in the wall of the blood vessel - if it bursts, it is likely to be fatal

       -can occur in the brain (in a part called the Circle of Willis) or in the abdomen (in the abdominal aorta)

       -syncope - temporary loss of consciousness due to decreased cerebral blood flow

       -paresthesia - abnormal sensation, such as burning, numbness, tingling, or prickling of the skin

 

 

 

 

 

 

 

 

 

 

 

V. Procedures

1. IV - this refers to an intravenous catheter - medicines and fluids are delivered through this tube

2. central line -  catheter that is passed through a vein to end up in the thoracic (chest) portion of the vena cava - usually performed when intravenous medication is necessary, but the doctors and/or nurses cannot get a regular IV in the patient's arm/leg

3. -endotracheal intubation - a flexible plastic tube that is put in the mouth and then down into the trachea (the airway). The doctor inserts the tube under direct vision with the help of a laryngoscope - main purpose is to ventilate the lungs

4. gastic lavage (NG tube) - removing contents from stomach by inserting an NG tube (tube inserted up nose, down throat, and into stomach) and suctioning out gastric contents

5. foley catheter - flexible tubes that are passed through the urethra into the bladder to drain urine

6. lumbar puncture (spinal tap) -  diagnostic procedure that is performed in order to collect a sample of cerebrospinal fluid (CSF) for analysis - often used check for meningitis

Important: central lines, endotracheal intubations, incision & drainage of abscesses, and lumbar punctures need special documentation within the chart. All three have special forms under the "Procedure" tab. Scroll down the chart until you see "Procedure" (its under "Documentation Reviewed"). Then right click on "Procedures," click "Insert Sentence" and click on either "Endotracheal Intubation," "Central Venous Line Placement," "Incision and Drainage," or "Lumbar Puncture." Then click enter.

 

1. Endotracheal Intubation note:

       Time: insert time of intubation        Confirmed correct: click on both patient and procedure        Indication: ask the doctor - usually you circle "Airway protection & maintenance"        Airway assessment - you can leave this blank, unless you know the O2 sat of the patient just prior to intubation - if you know this, insert the number under "Pre procedure 02 sat"        In-line stabilization: leave blank, unless otherwise indicated        Rapid sequence: leave blank, unless otherwise indicated        Pre-treatment: always circle oxygen - ask the doctor if any other pre-treatments were used        Sedation: ask the doctor        Paralytic drugs: ask the doctor        Cricoid pressure: leave blank unless otherwise indicated        Tube site: 99% of the time, you will circle "Oral" but if the doctor does inset the tube up the nasal cavity, then circle "Nasal"        Blade: click "Curved"        ET tube: this is referring to the size of the tube - its very important to ask the doctor which size tube he used and document it correctly

       # of attempts: insert number of attempts needed to inset the tube        Alternative Airway Device: leave blank, unless otherwise indicated        Breath sounds after intubation: click Equal        Breath sounds after ETT adjustment: only click on Equal here if the doctor had to adjust the tube once it was inserted        02 saturation: look on the monitor in the patient's room to record the 02 sat. Watch the monitor (or ask a nurse or the doctor) to see what the patient's lowest 02 sat was        Performed by: insert the doctor's name

 

2. Central venous line placement note:

       Indication: you will almost always circle "IV access," but check with the doctor if you're not sure        Consent form: circle Yes if the patient signed a consent form, otherwise circle NA        Confirmed correct: click Patient, Procedure, and Side        Location: ask the doctor        Preparation: click Topical Betadine, Sterile drapes, Cardiac monitor, and Pulse Ox. Only circle 02 if the patient is receiving oxygen.        Local anesthesia: ask the doctor        Catheter: click Triple Lumen        Technique: click J Wire and Introducer        Post Procedure Blood Return: click Good, unless otherwise indicated        Post Procedure Breath Sounds: click Normal, unless otherwise indicated        Post Procedure CXR: click Line Position Good, unless otherwise indicated        Post Procedure Pt Condition: click Improved, unless otherwise indicated        Procedure tolerated: click well, unless otherwise indicated        Performed by: insert the doctor's name

 

3. Lumbar puncture note:

       Indication: ask the doctor        Informed consent: click yes if the patient signed a consent form - otherwise click NA        Confirmed correct: click Patient, Procedure, and Side        Location: this is very important - be sure to ask the doctor and document correctly        Patient position - if patient is lying on his side, click Left Lateral Side; if patient is sitting up, click Sitting Bending Forward        Preparation: click Betadine and Sterile Field        Local anesthesia: ask the doctor        Spinal needle size: ask the doctor        Technique: leave blank, unless otherwise indicated        Opening pressure: ask the doctor

       Spinal fluid return: click whatever color/consistency is appropriate        Procedure tolerated: click well, unless otherwise indicated        Post motor and sensation: click Normal, unless otherwise indicated        Performed by: insert doctor's name

 

4. Incision and Drainage note

       Location: click "Describe" and type in the location of the abscess        Confirmed correct: click "Patient" "Procedure" and "Side"        Sites treated: click "Single" if there was one site to be drained; click "Multiple" if there was more than one site that needed to be drained        Degree of complexity: ask the doctor        Anesthesia: ask the doctor - usually 2-3 cc of Lidocaine with epinephrine is used        Prep - click "Betadine" or "Wound Cleanser" if the doctor cleanses the site prior to draining        Substance obtained: click "Describe" and type out what kind of exudate was drained (pus = purulent exudate, blood = bloody exudate, clear fluid = serous exudate)        Packing: click yes if the doctor packed the site with packing gauze, otherwise click no        IV Antiobiotics administered: click yes if the doctor administered antibiotics, otherwise click no        Drain placed: click yes if a drain was placed, otherwise click no        Cultured: click yes if the a sample from the wound was cultured, otherwise click no        Irrigation: click yes if the site was irrigated with normal saline, otherwise click no        Post assessment: click "Describe" and type out "condition improved"        Performed by: insert the doctor's name

 

 

 

 

 

 

 

 

 

 

VI. Abbreviations

        HTN - hypertension

        DM - diabetes mellitus 

        BKA - below-the-knee amputation

        AKA- above-the-knee amputation

        AMA - against medical advice

        DOA - dead on arrival

        TOD- time of death

        LOC- loss of consciousness

        CTA- clear to auscultation (referring to lung sounds)

        CAD - coronary artery disease

        PTA - prior to arrival

ESRD – end stage renal disease

 

 

 

 

 

 

 

 

 

VII. Lab/electrolyte values

Normal lab values:

Electrolytes Calcium 8.8 - 10.3 mg/dL Calcium, ionized 2.24 - 2.46 meq/L Chloride 95 - 107 mEq/L Magnesium 1.6 - 2.4 mEq/L Phosphate 2.5 - 4.5 mg/dL Potassium 3.5 - 5.2 mEq/L Sodium 135 - 147 mEq/L Lactic acid  (meq/L) 0.7 - 2.1 Lipoproteins and triglycerides Cholesterol, total < 200 mg/dl HDL cholesterol 30 - 70 mg/dl LDL cholesterol 65 - 180 mg/dl Triglycerides 45 - 155 mg/dl  (< 160) Complete blood count (CBC)  Adults   Male Female Hemoglobin (g/dl) 13.5 - 16.5 12.0 - 15.0 Hematocrit (%) 41 - 50 36 - 44 RBC's ( x 106 /ml) 4.5 - 5.5 4.0 - 4.9 WBC (cells/ml) 4,500 - 10,000 Creatinine (mg/dl) 0.5 - 1.4 Blood Gases   Arterial Venous pH 7.35 - 7.45 7.32 - 7.42 pCO2 35 - 45 38 - 52 pO2 70 - 100 28 - 48 HCO3 19 - 25 19 - 25 BUN 7 - 20 mg/dl

VIII. Anatomical positions

a) front and back

anterior/ventral -toward the front of the body

posterior/dorsal - toward back of the body

b) above and below

superior - above, towards the skull

inferior - below, towards the feet

 

c) close to or away from the center of the body

proximal means closer to the trunk (chest)

distal is away from the trunk (chest)

 

d) Near or Away from the Vertical longitudinal center of the body

medial - toward the midline of the body

lateral away from that median plane

 

e) Deep inside or Near the Surface

superficial - close to the surface of the body

deep - away from the surface

 

IX. Signs

a) Babinski -part of the neurologic examination based upon what the big toe does when the sole of the foot is stimulated. If the big toe fans out, this may be and indication of brain trauma, stroke, or spinal cord injury

b) Murphy's - performed by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder). The patient is then instructed to breathe in. Normally, during inspiration, the abdominal contents are pushed downward as the diaphragm moves down and lungs expand. If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner's fingers), the test is considered positive - used as an indicator for cholecystitis (gall bladder disease)

c) pronator drift -  refers to a pathologic sign seen during a neurological examination and indicates spasticity (which is due to an upper motor neuron lesion) - the patient is asked to flex his arms 90  degrees at the shoulders, supinate his forearms, close his eyes and hold the position - -if the one of the patient's arms begins to drift, then the patient is said to have a pronator drift on that side

d) Homan's sign - positive sign is present when there is pain in the calf with examiner's abrupt dorsiflexion of the patient's foot at the ankle while the knee is flexed to 90 degrees - can be used as evidence for DVT (deep venous thrombosis)

e) Hoffman's sign - a neurological test involving tapping the nail or flicking the terminal phalanx of the third or fourth finger. A positive response is seen with flexion of the terminal phalanx of the thumb