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Documentation
EMSS Training
| 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). |
| Location | The location of the chief complaint (i.e. left chest, lower abdomen, etc.) |
| Severity | The severity of the pain/chief complaint (i.e. mild, moderate, severe, 10/10) |
| Timing | The frequency of the chief complaint (i.e. constant, intermittent, waxing and waning) |
| Quality | The description of the chief complaint (i.e. sharp, burning, shooting, stabbing) |
| Onset | When the chief complaint began (i.e. 4 hours ago, 2 days ago, 20 minutes prior to arrival) |
| Context | Th circumstances surrounding the onset of the chief complaint (i.e. pain began while mowing lawn, vomiting began after eating an old burrito) |
| Associated Symptoms | Symptoms that are directly related to the chief complaint. |
| Modifying Factors | Anything that makes the chief complaint better or worse (i.e. pain is worse with walking) |
| Past, Medical, Family, Social History (PMFSHx) | Where you would document the patient's personal medical, surgical, family, and social history (previous conditions, etc.) |
| Medical History | This includes anything pertaining to the patient’s personal medical history (including pre-existing conditions or previous surgeries) |
| Family History | Contains the hereditary conditions of the patient’s immediate family members (parents, grandparents, siblings, etc.) |
| 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.) |
| 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. |
| 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) |
| ED Course | A chronological timeline of what occurred during a patient’s stay in the ED |
| EKG/ECG (Electrocardiogram) | A test that checks for problems with the electrical activity of the heart. |
| Procedures | Actions performed by the physician during a patient's stay in the Emergency Department (i.e. repairing a cut etc.) |
| Orders | Directions given by the doctor to perform tests or administer treatment/medications. |
| Radiology | The use of imaging to both diagnose and treat disease visualised within the human body. (i.e. x-rays, MRIs, CTs, etc.) |
| 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. |
| Prescription | A written document given to a patient authorizing a medicine or treatment. |
| 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) |
| Disposition | The plan for action after the patient leaves the Emergency Department (i.e. admitted to the hospital, discharged home, etc.) |
| Diagnosis | What the doctor has determined to be the cause of the patient's chief complaint/symptoms. |
| Condition | The current condition of the patient upon re-evaluation and/or discharge (i.e. improved, expired, worsened, unchanged) |
| 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.) |
Created by:
matteyoo
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