Essay About Abd Pain And Words Pt Uses

Scribe Notes
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Dr. Mahmood Vahediam, MD, MS, FACEPScribe Program DirectorScribe DutiesDocument ED provider/patient visitGoal: provider should just be responsible for reviewing and signing documentsImport all the external information to the patient medical chart (labs, imaging, medications, calls/consults, etc.)Facilitate the providers time management aka BABYSITTINGRemember to redirect provider as often as neededRelieve the provider from time consuming tasksUnderstanding Billing By Chart LevelsChart LevelBillingLevel 3$60.30Level 4$113.70Level 5$ 167.69Critical Care (after 3 re-evaluations ask provider to see if they want to bill as critical care)$208.91Difference between a level 3 and a level 4 chart is $53.38. Difference between a level 4 and a level 5 chart is $53.99.  **Take home message: time is money and we can’t afford to mess up the level of these charts with careless mistakes (messing up by 1 click)!**Understanding Billing By Chart Levels ContinuedChart Level12345Complaint–YesYesYesHPI–1-34+4+ROS–1+2-910+PFSH–NA12EXAM–2-45-78+Purpose of the Medical RecordPermanent document of patient careCommunication between various providersLegal document of carePurpose of the Scribe Sheet aka BFFHelp the scribe to organize the interaction between the provider and patient.Important tips to remember:Always record the room number on the scribe sheet (room number will be used more often to identify a patient then their name)Make the right side of the scribe sheet your BFFL9 Key Components of the POWERNOTEBasic informationHistory of Present Illnesses (HPI)Review of Systems (ROS)Health Status (allergies, medication history, etc.)Past medical/surgical hx, family hx and social hx **REMEMBER medical/surgical hx count as 1 for billing purposes**Physical Examination (PE)Medical Decision MakingProceduresDisposition**REMEMBER for any of the key components of the POWERNOTE, if you don’t know, leave it blank. DO NOT use inaccurate information.** [Basic Information]Time/date seen (timestamp powernote every time you re-enter it)History sourcePatient (unless unresponsive, altered, child, etc.)FamilyEMS (if transported by ambulance)Interpreter (must ass Ciracom ID/video/name of interpreter) **REMEMBER to ask for interpreter name or card if not provided for you**Remember to use scribe macro, followed by first initial/last name. EX: J. VillaArrival mode (EMS, walking, public transportation, etc.)Import nurses chief complaint (needed for every level of chart)Nurse’s chief complaint is a concise statement describing symptoms.**Note: if nursing note differs from what patient states, address this in HPI. EX: Contrary to triage note, pt denies CP.** [HPI]Story from pt/what the pt tells usProvider asks questions to get clearer picture about what is going on5 components to HPI:PainY/N PainLocation: Location of painPt may point to the area EX: abd pain but points to the suprapubic areaWe need to be watching the pt as they describe their story to see if they identify anywhere significant to the HPI with body language. QualityType of pain the pt is experiencing (description of pain)Pain can be described as: sharp, dull, achy, throbbing, burning, pressure, etc. If pt uses a word that isn’t a medical term, ex: pain like “fire” or “a knife”, place the words pt uses in quotations. **This will also be a common practice for psych pts. **RadiationWhere does the pain radiate (travel) to?FYI: pain usually radiated distally from the point of painEx: back, flank, testicles, shoulders, leg, neck, etc.SeverityUsually a numerical value on a pain scale of 0 to 10: 5/10We can use the “other” option to add the numerical value to the POWERNOTECan be measured currently, at onset, and at maximumTimingOnset- when did it start **REMEMBER this needs to be written in minutes, hours, days, weeks ago, etc.**Nature of onset (sudden/gradual)Constant, waxing & waning (pain always present, but at times worsens and increases in intensity), episodic, increasing, decreasing, resolved, etc.**REMEMBER that when a pt uses the word “sudden”, it is a red flag and we need to be paying attention to the provider’s follow-up to their definition of sudden. Ask provider to use this word in the POWERNOTE.**HPI modifying factors:What makes your pain/symptoms worse (aggravating factors). Ex: Pain worsens with rest.What makes your pain/symptoms improve (relieving factors). Ex: Pain improves with rest.Associated symptoms:Part of the investigation work that the provider doesMatches ROS **(REMEMBER this means that I MUST read and pay attention to things already marked in ROS)**HPI pertinent positives and negatives:RUQ pain: +/- GB removal, vomiting, cough, SOBVomiting blood: +/- ASA (aspirin), motrin, alcohol use, h/o liver disease, anticoagulant use, h/o same. ASA, motrin, alcohol are irritants to the stomach and can cause bleeding to the stomach. Ex of anticoagulants: Coumadin/warfarin, PlavixPelvic pain: +/- sexual activity, abnormal discharge, LMP, flank pain, h/o ectopic pregnancies, UTI symptomsHeadache: h/o SAH, CTD, HTM, photophobia, numbness, weakness, speech difficultySOB: cough, asthma, home oxygen use, fever, cp, h/o CVDZ, h/o DVT or PE, h/o same, recent travel, surgeryCP: +/- SOB, smoking, h/o CAD (including family members), hyperlipidemia, HTN, DVT/PEDangerous words that I MUST check with provider to use in HPI:SevereAcute onsetSudden onset“worst of my life”lethargicHPI OverviewP,Q,R,S,TAggravating/Alleviating factorsAssociated symptomsPertinent medical hxOther information stressed by the providerKnow the importance of spell checkAbdominal RegionsRUQEpigastricLUQRight HypocondriumPeri-umbilicalLeft HypocondriumRLQSuprapubicLLQLLQ: left lower quadrant