Scribe Notes

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LUQ: left upper quadrant

RLQ: right lower quadrant

RUQ: right upper quadrant

- 5 Areas of High Risk: If not part of the chief complaint, check with the provider on how to address in the POWERNOTE:

- Headache

- Vision change

- Chest pain

- SOB

- Abd pain

- Motor Vehicle Collision (MVC) Specific HPI Documentation

- 2 (lap) or 3 (lap and shoulder) point restraint (or not restrained)

- driver, passenger, rear driver side, rear passenger side

- involved in MVC with

- front (FPS,FDS) or rear (RPS,RDS) impact

- +/- airbag

- +/- head trauma

- +/- LOC

- +/- ambulatory

- +/- assisted out of car at scene

- presents with EMS (+/- backboard, +/- c collar), POV

- location of accident (public/private). Location of fall, injury or assault

- **REMEMBER this needs to be included according to government policies. Ask provider for this information!**

- Pregnancy Specific HPI

- Gravida _____ (# of pregnancies)

- Para _____ (# of live births)

- **REMEMBER if gravida and para numbers do not match up, we have to explain the discrepancy**

- At _____ weeks by LMS/UA

- Presents with (abd pain, vaginal bleeding, etc.)

- Ex: Pt is G#P# at _____ wks, calculated by _____ (LMS/US) presents with _____ (vag bleesing, abd pain, pelvic pain, discharge, etc). Now include 5 components of HPI

- P,Q,R,S,T what applies

- Associated symptoms

- Wprsening/improving factors

- Pertinent +/- (think of TSG)

- Additional information (blood type, OBGYN)

[ROS]

- Provider doing investigative work

- Information is obtained from the patient

- Review of the different organ systems

- Must have symptoms in 10 different systems to get level 5 chart

- **Ask provider if they want me to include: “All other systems negative except as noted above” to the end of their ROS. This is appropriate to include if at least 10 systems were retrieved, but make sure to ask provider**

- **REMEMBER ROS MUST MATCH HPI**

- If we can’t obtain the ROS from the pt we must mention why. Ex: due to AMS, due to severity of illness, due to dementia, due to pt being unresponsive, due to clinical condition, etc.

- Common errors on young pediatric ROS:

- No recent vision changes

- No ear pain

- No sore throat

- No chest pain

- No SOB

- No nausea

- No abdominal pain

- No dysuria

- No speech problems

- No headache, speech problems, numbness or tingling

[Health Status]

- Things that need to be imported in this section are allergies, medications list, etc.

[Past Medical/Surgical hx, family hx, social hx]

- Import what can imported from the nurses note

- If provider asks a question that a patient denies MUST state “pt/parent denies any significant surgical/medical hx”

- **REMEMBER to mark at least one thing for social hx**

- Adults: alcohol, tobaccp, drug use, employment, marital status

- Children: mark no concern for abuse, no concern for neglect, write parent (mom/dad) at bedside

[Physical Examination]

- Starts when the provider walks into the room

- When provider examines (touches) pt

- Some of the exam is done by observation (what is the patient doing/how is the patient acting)

- Ex: +/- distress, conjunctiva, mucus membranes, skin color, respirator distress, gross neurologic, psychiatric

- Alert & Oriented x3 means they know who, what ,where

- Important information to include in Pediatric PE:

- Appropriate for age and a general description of their appearance/behavior (smiling, drinking bottle, running around, eating, reaching for unknown objects, etc). Note that there is no petechiea or meningisumus (as seen in meningitis)

- **REMEMBER to ask provider before documenting anything regarding PERRLA, EOMI or CNII-XII intact**

[Medical Decision Making]

- What was done to/for the pt

- Orders= labs, imaging, medications, etc

- Results= labs, imaging, POC labs (pregnancy tests and lactic acid)

- EKG read and monitor strip read

- Specialist consult discussions documented (time specific, who the specialist was and what their recommendation for the pt was)

- Review of records= EMS notes, nursing notes, prior ER visits, prior records

- Re-evaluations of patients. **REMEMBER after 3 re-evaluations ask