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Terms in this set (83)
onset, timing, location, quality, severity, modifying factors, associated sx, context
A complete HPI has all of the following:
Pt presents for pruritic rash all over body which developed yesterday, noted to be large red bumps. First dog exposure outside 45 minutes before rash. Mom thought she had hives. Given Benadryl w/ mild relief noted to decrease size of bumps and itching.
Parent says: "My daughter, Katherine, was playing outside w/ her cousin's dog which is a Corgi for the first time for 45 minutes yesterday. She has never played w/ dogs before but she really gets along well w/ them. They were playing catch and she was running around outside w/ the dog. It was the cutest thing! She liked to pet the dog and threw the ball around the backyard playing fetch. She then came inside and immediately started scratching all over her body and had formed these large red bumps all over her body. i told her to stop itching, but she said she wouldn't stop. I thought she was going to make herself bleed from itching so much! She was really scratching everywhere! It looked like she had hives, but I wasn't sure so I gave her some Benadryl which stopped her from scratching and the red bumps went down some. I brought her in first thing in the morning because I didn't know what to do."
has decreased activity than normal, fatigued, has been sleeping more than normal
List 3 ways to document "lethargy", "listless", or "just not themselves" in the HPI.
lethargy, listless, unresponsive, inconsolable, toxic appearing
List 5 words commonly used by parents that you should not document unless explicitly asked to do so by the provider.
ask medical questions to pt, sign orders, touch pts, click into chart before pt is in office
List 4 things you can never do as a scribe.
pend orders and hit refresh on the chart
You are not allowed to sign orders, but you can __________.
click review tab at top of EPIC to review information in a pt's chart before the visit
You are not allowed to click into a chart to review pertinent info before the pt is in the office, but you can __________.
constant, intermittent, waxing/waning
descriptions for timing
Sharp, dull, aching, cramping, etc. describe what element of an HPI?
A 1-10 scale and mild/moderate/severe describe what element of an HPI?
UOP (urinary output)
What is one of the best indicators of hydration?
frequency of wet diapers
If the provider asks about __________, be sure to document it because UOP (urinary output) is one of the best indicators of hydration.
# oz pt is taking, at what time intervals, brand of formula/EBM (expressed breast milk), minutes per side if breastfeeding (and the answers to any other questions the provider may ask such as "Has your milk come in or do your breasts feel empty after feeding?")
What are 3 important things to document about feeding patterns?
adverse reaction, true allergy
N/v/d, abd pain, and dizziness would describe __________, while rash, itching, swelling, and SOB (due to airway swelling) describe __________.
rash, itching, swelling, SOB due to airway swelling
A true allergic reaction causes __________, __________, __________, and __________.
Constant fever for 5+ days is an indicator of __________ and other more serious conditions.
Be sure to document a fever as __________
100.4, fever, temperature, T max, tactile fever
Greater than __________F is considered __________, while less should be documented as __________. No matter the temperature, it is important to document the __________. If the parent says the child "felt warm", then document a __________.
longer than 5 days, increases over time, 103
A fever is concerning when it lasts __________, __________, or is greater than __________F.
A fever is considered an emergency in pts in the age range of __________ to __________.
How do you use spell check?
What can you write by a word if you are not sure how to spell it to bring it to the provider's attn. when they check the chart?
What can you put around text that you put your best guess for documentation you are unsure about fo draw attention to the provider?
PO intake (increased/decreased/solid intake/intake/appetite/etc.)
It is important to indicate the _____ to know if the pt is eating/drinking normally.
LOS (level of service)
Every visit must have a __________ associated w/ it which can be found in the tab labeled "Visit Navigator" and then select the "__________" tab.
One way to ensure proper upcoding of a visit to either an E4/N4 is to add __________ smart phrase and input the time interval that you have been in a room is over 25 minutes by using this smart phrase at the bottom of the visit note.
What 2 things determine how well child visits are coded?
Smart Set, pr pre
You may also select this in the "__________" with the corresponding age OR by typing "__________" in the search bar and finding the corresponding age and established versus new code. (*nurses usually enter the LOS for well checks)
LOS code for established pts
LOS code for new pts
double coding (modifier)
utilized when your provider has spent an excessive amount of tie discussing sick visit dx during a well child visit (sometimes parents bring up additional things to talk about)
LOS, wand, E3 and modifier 25, 25
Under the "__________" tab, click on the __________ which is located to the right side of the screen and select the __________ and associate it with the ssx of the sick visit coding. If you see "Modifier ____", aways enter __________.
pr pre, enter, age, established/new, Smart Set, age
If the nurse did not input the LOS, you may input the well child info by typing "__________" in the search bar, hitting __________, choosing the correct __________ and __________ for the coding. You may also input the coding by opening the __________ for the age interval.
asthma action plan
sick visit, well child visit, follow up (from ER, UC, or specialist), consultation
List 4 types of visits.
What type of visit is a visit to the pediatrician that pertains to the child having sxs of illness. During this time, the child will be dxed w/ a pediatric condition and can be given tx for that condition.
high pitched, continuous lung sounds, airway walls w/ their lumen narrowed
loud musical sound w/ constant pitch, indicates tracheal or laryngeal obstruction
strained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx
hoarse deep cough that sounds like a barking seal that indicates croup
A barky, seal-like cough indicates __________.
Pertussis is also known as __________.
continuous coughing sound followed by high pitched gasping sound
non productive cough, tickly, associated w/ allergies or viral illness, may also be an indicator of asthma sxs
productive (wet) cough
cough w/ phlegm or mucus
vomiting not associated w/ coughing, can be related to AGE or other GI conditions
post tussive emesis
vomiting associated w/ long coughing spells noted to vomit phlegm or mucus; not GI related
It is important to indicate if there is blood or mucus in the stool or indicate these are negatives; *note: if a pt has "looser stool" document it as such and NOT as __________.
__________ is the sensation of "the room spinning", feeling motion when still, and is commonly caused by inner ear problems. __________ is the sensation of feeling like you are about to faint (pre-syncope) and is mostly treated by lying down.
low blood pressure that occurs upon standing up; lightheadedness is commonly caused by this
phonophobia, photophobia, misophonia, hyperacusis, aura
What are 5 things often asked about when a pt complains of a HA?
sensitivity to sound; associated with migraine headaches
sensitivity to light, typically associated w/ migraines or other neurological conditions
sensitivity to specific sounds such as mouth breathing or chewing
sensitivity to certain frequencies; abnormally acute sensitivity to sounds
sensation perceived by a pt that precedes a condition affecting the brain such as a flashing light, blurred vision, odor, breeze feeling, numbness, weakness, or speaking difficulty, commonly occur before a migraine or seizure
well child visit
annual visit to the pediatrician in which the pt's growth and development are tracked; vaccinations are also updated during these visits
0-7 days old
newborn, 2 weeks, 1 mo, 2, 4, 6, 9, 12, 15, 18, 24, 30, 3 years, yearly
order of occurrence of well child visits
If a pt is exclusively breast fed or has EBM, then recommend giving __________ (vitamin D supplement).
sound or vibration heard due to flow through the heart heard on chest exam w/ stethoscope
innocent, benign murmur, most common PE finding: "2/6 SEM in LLSB"
palpable vibration on the chest wall accompanying severe heart murmur
questionnaire toddler screening tool for potential autism spectrum disorder (ASD)
autism spectrum disorder
ages and stages questionnaire
ASQ (tool used to evaluate if pt is on track developmentally)
ASQ (ages and stages questionnaire)
tool used to evaluate if pt is on track developmentally
asthma control test
ACT (asthma control test)
tool to evaluate how well controlled asthma sxs are at the time and if a change in meds management or tx plan is necessary
patient health questionnaire (aka depression screen)
PHQ9 (depression screening for 11 y/o and up)
screen to ID psychosocial problems in pts aged 4-11
edinburgh postnatal depression scale
EPDS (given at 2 week and 2 mo well checks; continue to discuss problems and the mother does not seek tx; refer mom to women's pavilion clinic for tx for positive screen results if they are not already receiving tx or planning to receive tx at another location)
EPDS (edinburgh postnatal depression scale)
given at 2 week and 2 mo well checks; continue to discuss problems and the mother does not seek tx; refer mom to women's pavilion clinic for tx for positive screen results if they are not already receiving tx or planning to receive tx at another location
parents evaluation of developmental status
MCHAT, ASQ, PEDS
What 3 questionnaires are specific for autism?
dx to monitor
A failed vision and hearing screen must be recorded as __________ (check this by looking at the hearing and vision test), suggest following up w/ optometrist/opthalmologist (depending on age) or potentially refer to audiology.
In pts under __________, 20/40 is still passing. Note that this needs to be monitored.
groups of orders and other elements, such as notes, cc's, pt instructions (will go over how to use in EPIC training).
used to treat umbilical granulomas (umbilical stump falls ff newborn but does not fully heal, so must cauterize using silver nitrate to help it heal)
- common cause of UMBILICAL MASS in NEWBORN
- appears AFTER UMBILICAL CORD HAS SEPARATED + presents as SOFT, MOIST, PINK, PEDUNCULATED, FRIABLE LESION
- Tx of choice = SILVER NITRATE
A small, scoop-shaped implement used for more efficient removal of debris from the nail folds, eponychium, and hyponychium areas. (used to remove cerumen from ears)
two methods that are used for cerumen removal
point of care
POC (done in clinic)
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