Term
| Name five things found in the MDM |
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Definition
| Medications, treatments, counseling, differential diagnosis, lab tests ordered, radiologic tests, procedures |
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Term
| How many elements are need for Cardiac Monitoring? |
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Definition
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Term
| What three things can be used for CM? |
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Definition
| rate, rhythm, and whether ectopy is present/absent |
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Term
| Pulse Oximetry requires what three things to be documented? |
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Definition
| percentage value, O2 details, and interpretation |
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Term
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Definition
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Term
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Definition
| arterial blood gas levels |
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Term
| How many elements are required for ECG? |
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Definition
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Term
| What are some things that can be used to document ECG? |
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Definition
| rate/rhythm, QRS complex, QT interval, ST segment, T waves, P waves, PR interval; interpretation; who interpreted it |
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Term
| what is need to document ABGs |
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Definition
| pH, O2, HCO3, CO2; interpretation |
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Term
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Definition
| # of views, 3 findings, & "interpreted by" |
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Term
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Definition
| heart size, mediastinum, infiltrates, effusion |
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Term
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Definition
| bowel gas pattern, free air, free fluid, obstruction, stool amount |
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Term
| Ext X-ray possible findings |
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Definition
| alignment, fracture, fracture details, soft tissue |
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Term
| CT scans and MRIs are interpreted by a.... |
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Definition
| raidiologist; note the significant findings of each test |
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Term
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Definition
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Term
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Definition
| Comprehensive metabolic panel |
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Term
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Definition
| length, description, type/dose of anesthetic, type/extent cleaning, type of suture or closure material, method of closure, number of sutures |
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Term
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Definition
| technique, immpolization equip used, result, complications?, crutches?, who performed it |
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Term
| Conscious sedation documentation |
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Definition
| pre-sedation status, time it began, end, and duration, monitoring in place, post sedation status, type/dose of med administered |
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Term
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Definition
| reason, meds admin., equip. used, complications |
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Term
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Definition
| time the ED puts call out to the consult |
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Term
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Definition
| time they actually speak with consult |
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Term
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Definition
| an discussions the physician has with the pt in the ED |
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Term
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Definition
| weighing the probability of one disease vs another |
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