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EMSS Training

Quiz yourself by thinking what should be in each of the black spaces below before clicking on it to display the answer.
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Term
Definition
HPI (History of Present Illness)   Where you would document the history of the patient's chief complaint (explaining what brought them into the Emergency Department).  
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Location   The location of the chief complaint (i.e. left chest, lower abdomen, etc.)  
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Severity   The severity of the pain/chief complaint (i.e. mild, moderate, severe, 10/10)  
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Timing   The frequency of the chief complaint (i.e. constant, intermittent, waxing and waning)  
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Quality   The description of the chief complaint (i.e. sharp, burning, shooting, stabbing)  
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Onset   When the chief complaint began (i.e. 4 hours ago, 2 days ago, 20 minutes prior to arrival)  
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Context   Th circumstances surrounding the onset of the chief complaint (i.e. pain began while mowing lawn, vomiting began after eating an old burrito)  
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Associated Symptoms   Symptoms that are directly related to the chief complaint.  
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Modifying Factors   Anything that makes the chief complaint better or worse (i.e. pain is worse with walking)  
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Past, Medical, Family, Social History (PMFSHx)   Where you would document the patient's personal medical, surgical, family, and social history (previous conditions, etc.)  
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Medical History   This includes anything pertaining to the patient’s personal medical history (including pre-existing conditions or previous surgeries)  
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Family History   Contains the hereditary conditions of the patient’s immediate family members (parents, grandparents, siblings, etc.)  
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Social History   An age appropriate review of the patient’s past and current activities (i.e. tobacco use, employment, marital status, living status, drug use, alcohol use, homelessness, etc.)  
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Review of Systems (ROS)   Where you would document all of the patient's other subjective symptoms (both positive and negative) not related to the chief complaint.  
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Physical Examination (PE)   The objective process by which a doctor investigates a patient's body for signs of disease. (This is from the doctor's point of view)  
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ED Course   A chronological timeline of what occurred during a patient’s stay in the ED  
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EKG/ECG (Electrocardiogram)   A test that checks for problems with the electrical activity of the heart.  
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Procedures   Actions performed by the physician during a patient's stay in the Emergency Department (i.e. repairing a cut etc.)  
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Orders   Directions given by the doctor to perform tests or administer treatment/medications.  
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Radiology   The use of imaging to both diagnose and treat disease visualised within the human body. (i.e. x-rays, MRIs, CTs, etc.)  
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Labs   Tests performed on body fluids and excretions (i.e. blood, urine, stool, etc.) in order to get information about the health of a patient.  
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Prescription   A written document given to a patient authorizing a medicine or treatment.  
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Vital Signs   Signs that may be watched, measured, and monitored to check an individual's level of physical functioning. (i.e. temperature, blood pressure, pulse oximetry, respiratory rate, heart rate/pulse)  
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Disposition   The plan for action after the patient leaves the Emergency Department (i.e. admitted to the hospital, discharged home, etc.)  
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Diagnosis   What the doctor has determined to be the cause of the patient's chief complaint/symptoms.  
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Condition   The current condition of the patient upon re-evaluation and/or discharge (i.e. improved, expired, worsened, unchanged)  
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Caveat   An acceptable reason as to why the physician is unable to obtain a patient's complete history (i.e. obtunded, altered mental status, seizure, etc.)  
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