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EMSS Training

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